
Book. .I&3 

GqpgtaW. L^2i_ 



COPYRIGHT DEPOSfT. 



Nutrition and Clinical 
Dietetics 



BY 
HERBERT S. CARTER, M.A., M.D. 

ASSISTANT PROFESSOR OF MEDICINE, COLUMBIA UNIVERSITY; ASSOCIATE ATTEND- 
ING PHYSICIAN TO THE PRESBYTERIAN HOSPITAL; CONSULTING 
PHYSICIAN TO THE LINCOLN HOSPITAL, NEW YORK 



PAUL E. HOWE, M.A., Ph.D. 

ASSOCIATE IN ANIMAL PATHOLOGY, ROCKEFELLER INSTITUTE FOR MEDICAL 

RESEARCH; FORMERLY ASSISTANT PROFESSOR OF BIOLOGICAL CHEMISTRY, 

COLUMBIA UNIVERSITY, N. Y.j NUTRITION OFFICER, CAMP KEARNY, 

CALIFORNIA; OFFICER IN CHARGE OF LABORATORY OF NUTRITION 

ARMY MEDICAL SCHOOL, WASHINGTON", D. C. 



HOWARD H. MASON, A.B., M.D. 

INSTRUCTOR IN DISEASES OF CHILDREN, COLUMBIA UNIVERSITY, NEW YORK J 

ASSOCIATE ATTENDING PHYSICIAN TO THE PRESBYTERIAN HOSPITAL; 

ATTENDING PHYSICIAN TO THE RUPTURED AND CRIPPLED 

HOSPITAL, NEW YORK 



SECOND EDITION, THOROUGHLY REVISED 




LEA & FEB IGER 

PHILADELPHIA AND NEW YORK 
1921 



*«• 



*tv 



x* 



Copyright 

LEA & FEBIGER 

1921 



©CU605791 
FEB Id 192! 



PREFACE TO THE SECOND EDITION 



The Authors present the second edition of Nutrition and 
Clinical Dietetics with the hope that it may be found in- 
creasingly useful to the general student body as well as to 
the practitioner. 

In Parts I and II there has been made an adequate re- 
vision of the chapters on Energy, Metabolism and Digestion, 
particularly with regard to the physiology of digestion; also 
an entire revision of the chapter on Vitamines, and as well a 
new chapter on Metabolism in Pregnancy and Lactation 
together with the Feeding of Children over Two Years 1 d. 

In Part III there has been a general overhauling of the 
material in the light of the more recent literature. To Part 
IV there have been added some fifty odd pages of new ma- 
terial gathered from a careful review of the subject of Diet- 
etics in Disease as found in the publications of the past 
three years. These additions have been chiefly in the form 
of the amplification of already existing chapters. In all 
parts of the book obsolete matter has been eliminated. 

H. S. C. 
P. E. H. 
H.H.M. 



CONTENTS 



Introduction 17 



PART I. 
FOODS AND NORMAL NUTRITION. 

CHAPTER I. 
Digestion, Absorption and Excretion. 

Digestion 23 

Enzyme Action 23 

Oral Digestion 25 

Gastric Digestion 27 

Appetite 31 

Hunger . . 34 

Intestinal Digestion 35 

Sensibility of the Alimentary Canal 37 

Absorption 38 

Bacterial Action and Feces 42 

Intestinal Bacteria . . 42 

Putrefaction and Feces 44 

Excretion 48 

Digestibility of Food 52 

CHAPTER II. 
Energy Requirement. 

Caloric Value of Food-stuffs 56 

One Hundred Calory Portion 57 

Determination of Energy Requirement 59 

Respiration Apparatus 59 

Respiratory Quotient .... 60 

Basal Metabolism 60 

CHAPTER III. 

Protein Requirement. 

Standard Dietaries — Average Protein Requirement 80 

CHAPTER IV. 
Inorganic Salts and Water. 

Chlorine Requirement of Man 87 

Phosphorus Requirement of Man 89 



vi CONTENTS 

Calcium Requirement of Man 92 

Iron Requirement of Man 96 

Iodine Requirement of Man 98 

Water Requirement of Man 99 

Vitamines and Accessory Food-stuffs 102 

Scurvy 107 

Pellagra iti 

Rickets 11 1 

CHAPTER V. 

Food Requirements in Pregnancy and Lactation. Food Requirements 
and Feeding of Children. Fasting. 

Food Requirements of Pregnancy and Lactation 112 

Energy 112 

Protein Requirement 113 

Diet and Lactation 115 

Food Requirements and Feeding of Children 116 

Energy Requirement of Children ^ 117 

Protein Requirement " 118 

Inorganic Salts 120 

Vitamines : 120 

Water .121 

Selection of Diets for Children after the Second Year 121 

Food for Children . 122 

Planning the Meals 124 

Food Habits of Children 124 

Fasting 126 

CHAPTER VI. 
Normal Feeding and Food Economics. 

Requisites of a Complete Diet 130 

Suggested Menus . . . . . , . . . . 137 

Factors which Determine the Cost of Food 136 

Unbalanced Diets 146 



PART II. 

FOODS. 

CHAPTER VII. 

Introduction — Milk. 

Milk 150 

Chemical Properties 151 

Protein 152 

Fats 153 

Carbohydrates 153 

Salts . . . . 154 

Variations in Composition 155 

Influence of Temperature upon Milk 158 

Condensed Milk . 156 

Action of Bacteria 159 

Action of Heat 159 

Digestion of Milk 160 



CONTENTS vii 

CHAPTER VIII. 
Protein Foods. 

I. Protein Proteins 166 

Albumins 166 

Globulins; Glutelins; Alcohol Soluble Proteins (Prolamines); Al- 
buminoids; Histones; Protamines 167 

II. Conjugated Proteins 168 

Nucleoproteins; Glycoproteins; Phosphoproteins; Hemoglobins; 168 

Lecithoproteins .. 169 

III. Derived Proteins . 169 

A. Primary Protein Derivatives 169 

Proteins; Metaproteins; Coagulated Proteins . . . . 169 

B. Secondary Protein Derivatives 169 

Proteoses; Peptones; Peptides 169 

Influence of Heat ..." . 169 

Effect of Low Temperatures 170 

CHAPTER IX. 
Meat or Flesh Food. 

Effect of Heat on Meat 177 

Precise Method of Roasting Beef . . 179 

Chemical Changes of Meat as the Result of Cooking 180 

Digestibility of Meat 180 

Meat Preparations 183 

Meat Extracts 185 

Meat Juices 185 

Meat Broths 185 

Gelatin 186 

CHAPTER X. 

Fish and Shell Fish — Poultry and Game. 

Fish and Shell Fish 188 

Cold Storage Fish; Preserved Fish; Cooking of Fish 191 

Digestibility of Fish 192 

Poultry and Game 192 

CHAPTER XI. 

Eggs and Cheese. 

Eggs 194 

Egg White; Egg ^ oik 195 

Cooking of Eggs 196 

Digestibility of Eggs 197 

Preserved Eggs 198 

Egg Substitutes 199 

Cheese 199 

Digestibility of Cheese; Casein Preparations 200 

CHAPTER XII. 

Protein-rich Vegetable Foods. 

Legumes in General 202 . 

Soy Bean 204 

Peanut; Preparation of Legumes 205 

Nuts 206 



viii CONTENTS 

CHAPTER XIII. 
Carbohydrate-rich Foods. 

Sugars ' 208 

Sucrose 208 

Glucose 209 

Lactose 209 

Maltose 210 

Maple-sugar; Invert sugar; Fructose 210 

Candy; Jams and Jellies 210 

Digestion and Utilization of Sugar 211 

Starch-rich Foods . 213 

Grains and their Products 214 

Barley; Buckwheat 216 

Corn 216 

Oats; Rice 217 

Rye 218 

Wheat 218 

Bread 221 

Baking Powders 222 

Rolls, Biscuits, Muffins, etc.; Biscuits; Crackers; Cakes; 

Breakfast Foods 223 

Macaroni 223 

Celluloses 224 

Potatoes 224 

CHAPTER XIV. 
Fat- rich Foods. 

Cream 231 

Butter 232 

Renovated Butter and Butter Substitutes . 233 

Oleomargarine ' . 234 

Lard 235 

Cotton Seed Oil 235 

Olive Oil 236 

Corn Oil 236 

Cod-liver Oil 236 

CHAPTER XV. 
Foods Valuable for Their Salts, Water, and Bulk. 

Fruits and Vegetables . . . 242 

Cooking of Vegetables and Fruits 242 

Food Adjuncts 244 

Flavoring Extracts; Meat Extracts; Vinegar; Sugar and Salt (Sodium 

Chloride) ; Sugar Substitutes 245 

Beverages 245 

Tea 246 

Coffee . . 247 

Cocoa and Chocolate 250 

Mineral Waters 252 

Radio-active Water . 254 

Alcoholic Beverages 257 

Wines; Malt Liquors 260 

Malt Extracts 261 

Distilled Liquors . 262 



CONTENTS ix 
PART III. 

FEEDING IN INFANCY AND CHILDHOOD. 

CHAPTER XVI. 

Breast Feeding — Feeding Normal and Abnormal Children. 

Woman's Milk 263 

Colostrum 263 

General Characteristics of Woman's Milk 264 

Quantity 264 

Composition " 265 

Fat; Lactose ... 265 

Protein; Salts; Iron; Phosphorus 266 

Salts of Woman's and Cow's Milk 267 

Bacteria; Drugs; Nervous Impressions; Pregnancy; Transmission 

of Immunity; Diet 268 

Breast Feeding 268 

Contra-indications for Breast Feeding 269 

Intervals of Nursing; 269 

Length of each Nursing 270 

Mother's Diet and Exercise 270 

Vomiting 272 

Gas and Colic 272 

Abnormal Stools 273 

Mixed Feeding 273 

Weaning 274 

CHAPTER XVII. 

Artificial Feeding. 

Food Requirements of the Artificially-fed Infant 276 

Energy 276 

Protein; Fat 277 

Carbohydrate 278 

Sugar 278 

Starch 279 

Inorganic Salts; Water 280 

Proprietary Foods 280 

Preparations Containing Cow's Milk; Preparations Containing Large 

Amounts of Maltose 281 

Farinaceous Foods; Miscellaneous Foods 281 

Artificial Feeding . 282 

Method of Preparing Formulae 283 

Increasing Formulas 283 

Cereal 284 

Higher Fat Mixtures 285 

Food Other than Milk 287 

Beef Juice and Broth; Beef Juice; Cereals 287,288 

Egg; Vegetables; Rice and Potato; Bread 288,289 

Abnormal Symptoms 289 

Vomiting; Gas; Colic 290,291 

Loose Stools; Diarrhea . 291 

Constipation 29^ 

CHAPTER XVIII. 

Feeding of the Premature Infant. Feeding after the First Year. 
Feeding during Acute Illness and in Nutritional Disturbances. 

Feeding of the Premature Infant 294 

Feeding during the Second Year 295 

Feeding after the Second Year 296 



x CONTENTS 

Feeding during Acute Infections 297 

Infants 297 

Gavage 298 

Children Over One Year 298 

Gavage; Long Illness 298 

Pyloric Stenosis 299 

Cyclic Vomiting . . - " . . . . 300 

Feeding in Nutritional Disturbances • .• 302 

Rickets 302 



PART IV. 

FEEDING IN DISEASE. 

CHAPTER XIX. 

Diet in Diseases of the Circulatory Organs. 

Functional Cardiac Disturbances . . . . . . 308 

Diet in Organic Cardiac Disease 308 

Cardiac Decompensation 309 

The Karell Cure; Potter's Modification of the Karell Cure . . 310 

Fatty Heart 312 

Adolescent Heart and Cardiac Myasthenia following Infectious Disease 313 

Senile Heart 313 

Diet in Diseases of the Bloodvessels 314 

Arteriosclerosis 314 

Diet in Hypertension 315 

The Effect of Various Substances on Blood-pressure 316 

Aneurysm . 316 

Angina Pectoris; Tobacco in Relation to Cardiac Disease . . . . 316 

CHAPTER XX. 
Diet in Diseases of the Lungs. 

Pneumonia 318 

Bronchitis 320 

Acute Bronchitis 320 

Chronic Bronchitis . ' . . 321 

Emphysema . *: 322 

Asthma '. 323 

Pleurisy with Effusion. Hydrothorax 325 

Empyema . 325 

Tuberculosis, Pulmonary or General 326 

Prophylaxis for Children of Tuberculosis Inheritance 330 

Special Foods for the Tuberculous 331 

Milk; Eggs; Fats 331 

Complications 333 

General Rules for Feeding in Tuberculosis 334 

CHAPTER XXI. 
Diet in Diseases of the Stomach. 

Indigestion . . . . 336 

Gastric Hyperacidity, Hyperchlorhydria 338 

The Reduction of Gastric Hyperacidity by Diet 340 

Diet in Hyperacidity 341 

Gastric Hypersecretion . 342 

Gastric Hypoacidity and Achylia Gastrica 343 



CONTENTS xi 

Gastritis 346 

Acute Gastritis 346 

Chronic Gastritis 347 

Diet when Gastritis is Accompanied by Hypoacidity or Achylia . 348 

-Peptic Ulcer (Gastric and Duodenal) 349 

von Leube Diet in Ulcer 350 

Lenhartz Diet 353 

Sippy Diet 360 

Modified Diet 364 

Ambulatory Diet 365 

Transgastric or Duodenal Feeding 367 

Diet after Hemorrhage from Stomach or Duodenum 369 

Gastric Atony 370 

General Directions in Gastric Atony 371 

Organic Gastric Acidity 374 

Carcinoma of Stomach 375 

Gastric Dilatation 378 

Gastric Neuroses 379 

Secretory Neuroses; Neuroses of Sensation 380 

Motor Neuroses 381 

Gastric Test Meals 381 

Gastric Motor Meals 382 

CHAPTER XXII. 
Diet in Diseases of the Intestines. 

Acute Enteritis 385 

Chronic Enteritis 386 

Schmidt Test Diet 387 

Acute Colitis or Acute Dysentery 389 

Chronic Colitis 390 

Membranous Colitis, Mucous Colic or Chronic Mucous Colitis .... 391 

Ulceration of the Small or Large Intestine 392 

Intestinal Hemorrhage 392 

Diarrhea 393 

Dietary Regulations 394 

Foods to Avoid in Chronic Diarrhea; Foods Recommended in 

Diarrhea; Foods Allowed in Certain Cases 395 

Intestinal Neuroses 396 

Chronic Constipation 397 

Atonic Constipation 398 

Spastic Constipation 400 

Obstructive Constipation 400 

The Use of Mineral Oil in Chronic Constipation 401 

Intestinal Atony 402 

Appendicitis 403 

Acute Appendicitis 403 

Ochsner's Treatment for Appendicitis 403 

Chronic or Larval Appendicitis 405 

Chronic Typhlitis or Perityphlitis 406 

Intestinal Auto-intoxication 406 

Hemorrhoids 412 

Hirschprung's Disease 413 

CHAPTER XXIII. 
Diet in Diseases of the Accessory Digestive Glands. 

Diseases of the Liver and Gall-bladder 414 

Dietetic Prophylaxis 413 

Acute Hepatic Congestion; Acute Catarrhal Jaundice or Gastro- 

duodenitis with Jaundice 416 



xii CONTENTS 

Diseases of Liver and Gail-Bladder: 

Chronic Hepatic Congestion; Portal Cirrhosis 417 

Biliary Cirrhosis; Fatty Liver 418 

Acute Yellow Atrophy of Liver 410/ 

Amyloid Liver; Cholelithiasis . . 419 

Prophylactic or Postoperative Diet 420 

Acute Cholecystitis and Colic 421 

Pancreatic Disease 422 

Acute Pancreatitis 422 

Chronic Pancreatitis 423 

CHAPTER XXIV. 

Diet in Diseases of the Skin. 

Psoriasis 426 

Eczema 428 

Acute Eczema; Chronic Eczema 429 

Eczema in Nurslings 430- 

Acne Rosacea -431 

Acne Vulgaris 432 

Erythema . . 432 

Pruritus 433. 

Dermatitis 434 

Dermatitis Herpetiformis; Exfoliative Dermatitis 434. 

Furunculosis; Comedones 435 

Hyperidrosis 435 

CHAPTER XXV. 

Diet in Diseases of the Genito-urinary System. 

Nephritis . . 436 

Kidney Dietary Tests ... . 439 

Water Excretion; Salt Excretion; Nitrogen Excretion 439 

Albuminuria 445 

Acute Nephritis 446^ 

Chronic Nephritis 449 

Dietetic Management of Chronic Nephritis . . 449 

Diets in Chronic Nephritis; Diets for Cases with Nitrogen Retention 

(Chronic Uremia) 450- 

Diet in Water Retention; Edema 451 

Diet in Salt Retention 452 

Pyelitis 456- 

Cystitis 457 

Gonorrhea 457 

Nephrolithiasis 457 

Amyloid Kidney 45& 

CHAPTER XXVI. 

Diet in Diseases of Pathological States due to Disturbances of 
Normal Metabolism. 

Diabetes Insipidus 459 

Diabetes Mellitus ... 4 6 ° 

The Relation of Protein Metabolism to Glycosuria 462 

The Nitrogen Balance in Diabetes 464 

Relation of Fat Metabolism to Glycosuria 465 

Hyperglycemia ... 466' 

Dietetic Treatment of Diabetes 467 

von Noorden Method . 468 

Standard Strict Diet . . . 469 

Standard Diet with Restricted Protein; Green Days . 470* 



CONTENTS xiii 

Diabetis Mellitus: 

Dietetic Treatment of Diabetes: 

Oatmeal Days; General Diabetic Diet List 471 

Foods Prohibited Except as Allowed in Accessory Diet . . . 472 

Foster's System of Carbohydrate Units 473 

Sample Diet; Procedure in Medium Severe Cases; Severe Cases 

with Marked Ketonuria 474 

Potato Diet; Bread-and-butter Diet; Allen's Treatment of Dia- 
betic Mellitus ... 475 

Joslin's Resume of Allen's Treatment 483 

Diabetic Special Receipts 485 

Diet for Diabetics with Gout; Diabetes in Elderly People or in the 

Young 489 

Diet for Obesity with Diabetes 490 

Diet in Diabetes Complicated by Nephritis 491 

Obesity 491 

Reduction Cures 496 

von Noorden's Cure 496 

Banting's Cure 498 

Oertel's Cure 498 

Ebstein's Dietary 499 

Schweninger's Dietary . ' 500 

Germain-See Diet; Tibbie's Milk Cure 500 

Salisbury Method; Tower-Smith's Modification of Salisbury Diet 501 

Galisch's Cure; Folin-Denis Method of Reduction 502 

Exercise and Massage; Water in Obesity 503 

Gout 504 

Foods in Gout 508 

Carbohydrates; Salts; Alcohol 509 

Coffee, Tea and Cocoa 509 

Diet in Acute Gout or Podagra 510 

Diet for Leanness or Fattening Cures 514 

Foods to be used in Fattening 515 

Protein 515 

Carbohydrate 516 

Fat; Alcohol 517 

Phosphaturia 518 

Physiological Phosphaturia; Nervous and Sexual Phosphaturia; . 519 

Juvenile Type 520 

Phosphates and Calculi 520 

Diet Recommended for Calculi 521 

Oxaluria 521 

Diet in Oxaluria 521 

Diet in Old Age 522 

Food Requirements of the Aged * 523 

Foods Especially Desirable for the Aged 525 

Preparation of Food for the Aged 527 

Diet Routine in Old Age 528 

Osteomalacia 529 

CHAPTER XXVII. 
Diet in Blood Diseases. 

The Anemias . 530 

Treatment of Chlorosis 531 

Iron 532 

Diet in Chlorosis 533 

Diet in Anemia (Chlorosis) . . 533 

Secondary Anemia; Pernicious Anemia 535 

Posthemorrhagic Anemia 537 

Leukemia 537 

Hemophilia 537 

Purpura Hemorrhagica 538 



xiv CONTENTS 

CHAPTER XXVIII. 
Diet in Deficiency Diseases. 

Scur yy •. Q 539 

Diet in Scurvy < 540 

Beriberi . . ... . . . ■ . 541 

Xerophthalmia 543 

Pellagra 543 

Goldberger's Conclusions 544 

Diet in Pellagra 545 

CHAPTER XXIX. 
Diet in Diseases of the Nervous System. 

Organic Nervous Diseases 547 

Neuritis 547 

Epilepsy 548 

Insanity ' 549 

Apoplexy . . 550 

Functional Nervous Diseases 551 

Migraine or Periodic Headaches 551 

Chorea; Neurasthenia 553 

Weir Mitchell Diet and Treatment 555 

Digestive Neuroses; Insomnia 557 

Delirium Tremens 558 

Nervous Anorexia 559 

CHAPTER XXX. 

Diet in Acute and Chronic Infections. 

Fever . . . . . 560 

Diet in Fever 563 

Carbohydrates; Protein . 564 

Fats 566 

Beverages; Intervals of Feeding; Alcohol . ....... 566 

Typhus Fever 567 

Typhoid Fever 568 

Older Diets 569 

Bacteriological and Physiological Basis for More Liberal Diets . 569 

Carbohydrates 570 

Fats; Protein 571 

Energy Requirement 572 

Results Obtained by Liberal Diet 572 

Typhoid Diets ■ 573 

Diet in Typhoid Complications 583 

Intestinal Hemorrhage , 583 

Perforation ; Nausea and Vomiting . 584 

Water; Paratyphoid Fever 584 

Malaria Fever 584 

Scarlet Fever 584 

Smallpox • 585 

Cerebral or Cerebrospinal Meningitis . . 585 

Measles 586 

Influenza (Grippe) 586 

Acute Articular Rheumatism 587 

Diet in Acute Articular Rheumatism . . . . 588 

Subacute Rheumatism .. . . . . . 589 

Chronic Rheumatism (Chronic Infectious Arthritis) 589 

Tetanus 590 

Yellow Fever 590 

Cholera 591 

Dietetic Rules for Cholera 59 2 



CONTENTS xv 

Peritonitis . 594 

Acute Peritonitis 594 

Chronic Peritonitis 594 

Chronic Infections 594 

Rheumatoid Arthritis. Arthritis Deformans 596 

CHAPTER XXXI. 
Diet in Relation to Surgical Operations. 

Preoperative Diet 599 

General Directions for Cases of Laparotomy . 599 

Diet Preparatory to Gastric Operations 600 

Postoperative Diet 601 

Postoperative Diet for the Digestive Tube; Diet after Tonsillectomy; 
Postoperative Gastric Diets; Diet after Gastroenterostomy and 

Gastric Operations . 601 

Finney's Diet List following the Operation for Gastroenterostomy 605 

Intestinal Lesions 606 

Diet after Appendectomy 607 

Diet in Certain Complications following Abdominal Operations; Vom- 
iting 607 

Prevention of Desiccation of the Tissues 608 

Dietary Measures in Postoperative Intestinal Distention . . . 609 
Diet after Gall-bladder Operations; Diet after Operation for Hemor- 
rhoids 610 

Constipating Diet 611 

Feeding after Intubation 611 

CHAPTER XXXII. 
Diet in Diseases of the Ductless Glands. 

Acromegaly . . ' . .612 

Acute Thyroiditis 613 

Exophthalmic Goiter 613 

Diet to Meet Special Indications in Exophthalmic Goiter . . . .615 

Diarrhea 615 

Inanition ■ 616 

Myxedema or Cretinism 616 

Addison's Disease 616 

CHAPTER XXXIII. 
Diet in Miscellaneous Conditions. 

Artificial Methods of Feeding 618 

Rectal Feeding ..." 618 

Protein 619 

Fats; Carbohydrates 621 

Precautions in Rectal Feeding 622 

Subcutaneous Feeding 623 

Protein 623 

Fats; Carbohydrate 624 

Intravenous Feeding 625 

Diet in Pregnancy and its Complications 626 

Nausea and Vomiting of Pregnancy 626 

Nephritis 628 

Mild Auto-intoxication 629 

Contracted Pelvis or with Oversized Fetus 629 

Puerperium 630 

Foods Best Avoided; Diet List after Normal Confinement 630 

Sprue 6£i 



xvi CONTENTS 

Dental Caries 633 

Diet in Cancer . 634 

Diet Recommended for Speakers and Singers 636 

Diet Adapted to the Use of Brain Workers 637 

Diet for Athletes 637 

Sugar . . 639 

Foods to Avoid 640 

Feeding of Unconscious Patients . 640 

Food Poisoning 641 

Meat Poisoning; Fish Poisoning 642 

Vegetable Poisoning; Poisoning by Canned Goods 643 

Dietary Precautions 644 

Special Dietary Cures 645 

The Vegetarian Diet 645 

Metabolism of Vegetarians 647 

Vegetarian Diets 648 

Fletcherism 649 

Fruit Cures 652 

Grape Cure 653 

CHAPTER XXXIV. 
Food Protection. Accessory Food. Beverages. 

Flies. Food and Illness 654 

Beverages for the Sick 654 

Artificial Foods . 657 

Olive Oil and its Dietary Usage 658 

Stenosis of Esophagus; Pyloric Stenosis; Gastric Dilatation; Chole- 
lithiasis; Gastric Hyperacidity 658 

CHAPPTE XXXV. 
Tables of Food Values and Weights and Measures. 

Average Chemical Composition of American Foods 660 

Table of Measures and Weights 668 

Apothecaries' Measures 668 

Apothecaries' Weights 668 

Approximate Measures 668 

Relative Value of Metric and Apothecaries' Measures ...... 669 

Relative Value of Apothecaries' and Metric Measures ..... 669 

Relative Value of Metric and Avoirdupois Weights 669 

Relative Value of Avoirdupois and Metric Weights 670 

Relative Value of Apothecaries' and Metric Weights . . . . . . . 670 

Relative Value of Metric and Apothecaries' Weights 670 

Fisher's Table of One Hundred Calory Portions 671 

Table Showing the Nutritive Value of the Food Materials Calculated for 

the Quantities Commonly Required in Cooking Small Portions . . 677 



NUTRITION AND CLINICAL 
DIETETICS 



INTRODUCTION 

The term food may be applied to any material with the 
aid of which the body is able to maintain its characteristic 
functions: temperature regulation, the performance of work, 
the repair of wasted tissues, the production of new tissues, 
and those countless factors — connoted by digestion, absorp- 
tion, circulation, etc. — involved in the preparation and trans- 
portation of the ingested food to the seat of action of the 
prime factor of organization, the cell. 

In the various kinds of cells of a complicated organism 
such as the human body, transformations are in progress 
which are qualitatively similar but which vary quantita- 
tively according to their specific functions : thus w r e have the 
cells of the muscular system, whose chief function appears 
to be the performance of work and the liberation of energy 
for the maintenance of body temperature, or the cells of the 
glandular organs which form substances to be secreted into 
or from the body, and of the nervous system which are con- 
cerned in the conveyance of impulses. Whatever may be 
the specialized function of any cell, it is imbued with the 
fundamental characteristic activities of all cells. The sum 
total of the activities of the individual cell or of the body as 
a whole are grouped under the term metabolism, by which 
we mean "all chemical and physical changes which occur in 
living matter and which constitute the basis of the material 
phenomena of life." When such changes involve the trans- 
formation of simple into more complex substances, they are 
usually associated with an increase in the energy content of 
the compounds formed, and are designated as anabolic pro- 
cesses. Changes which are concerned with the disintegra- 
tion of complex material with the formation of simpler pro- 
ducts are designated as catabolic processes and are ordi- 
narily associated with the liberation of energy. By means 
of anabolic processes the products of digestion are built up 



18 NUTRITION AND CLINICAL DIETETICS 

into the active structural compounds of protoplasm, into 
secretions, or into complexes suitable for storage and future 
use. Such processes predominate in growth and in those 
organs or tissues associated with the elaboration of secretions. 
The catabolic processes involve a disruption of food-stuffs, 
of cell components, or of reserves, and the liberation of energy 
in the form of heat or mechanical work, the end-products of 
this activity being finally eliminated from the body. The 
cellular activities associated with muscular contraction and 
the regulation of body temperature are pre-eminently cata- 
bolic. In normal individual cells and in the body in general 
there is a nice balance between the anabolic and catabolic 
processes. Any disturbance of this equilibrium may resuk 
in a pathological condition. Considerations of diet in dis- 
ease are concerned almost entirely with alterations in the 
balance between anabolic and catabolic activities. 

Five important classes of food-stuffs are required to satisfy 
the needs of the body; the lack of any one of these would 
result in grave metabolic disturbances. They are: proteins, 
carbohydrates, fats and lipins, salts and water. To this list 
of general classes may be added a sixth, the accessory food 
substances designated as vitamines. 

The collective expression, food, is applied to naturally 
occurring combinations of the food-stuffs enumerated or to 
products from these. Since most foods are themselves con- 
glomerates of materials which have been associated with life, 
they contain in different proportions some of all the elements 
required by the human organism. Thus we have such foods 
as meat, eggs, etc., in which protein predominates, but which 
contain also fat, carbohydrates, water, and salts; or certain 
vegetable' foods whose solid material is largely carbohydrate 
and salts, with a very small proportion of protein and fat. 

The functions of the food-stuffs are varied; proteins, car- 
bohydrates, and fats may be utilized by the body as a source 
of energy, the greater proportion of the energy requirement 
of the body is supplied, however, by the carbohydrates and 
fats. Protein serves not only as a source of energy but as 
the source of amino-acids and radicles necessary for the for- 
mation of body protein, secretions, etc. Salts and water, 
while not the source of energy, are essential factors in the 
constitution and activity of all parts of the body. 

Proteins are, as we have just indicated, important as the 
chief source of nitrogen-containing substances necessary for 
life, being colloidal in nature and capable of combining with 
both acids and bases, and absorbing or entering into loose 
chemical combinations with salts and water, they share in a 
most varied activity in the body processes. 



INTRODUCTION 19 

In the cycle of life protein is synthetized in the vegetable 
kingdom, and this protein is utilized in the construction of 
animal protein. Animals appear to be unable to synthetize 
the greater number of amino-acids present in the protein 
molecule, particularly those containing cyclic nuclei. Plants, 
however, can form the amino-acids and conjugate them into 
protein. The animal organism is, then, dependent upon the 
plant for the basal units of its protein molecule. Before 
plant protein can be used it must be broken down into 
amino-acids or simple combinations of these, which are then 
built up into the type of protein characteristic of the particu- 
lar tissue concerned. The object of feeding is to supply not 
only protein to the individual, but protein which will furnish 
the proper kinds and amounts of amino-acids. 

The second class of food-stuffs, carbohydrates, are used by 
the body as a source of energy in the performance of its many 
internal activities as well as of external work. They are, 
apparently, more readily accessible for such purposes than 
protein or fat; in all cases in which a sudden expenditure of 
energy is involved or in states in which the body is forced to 
draw upon its reserve supplies the depots of carbohydrate 
(glycogen) are the first to become depleted, after which the 
fats and proteins furnish the required nutritive materials. 
The absence of carbohydrates from the diet often results in 
pronounced metabolic disturbances, e. g., acidosis. 

Chemically, carbohydrates consist of carbon, hydrogen, and 
oxygen ; the hydrogen and oxygen being often present in the 
proportions in which they occur in water. This last fact was 
responsible for the name. From the structural point of view 
we find carbohydrates to be oxidation products of polyhydric 
alcohols (ketone- or aldehyde-alcohols). Human food usually 
contains molecules consisting of chains of five or six carbon 
atoms or multiples of these. Starch, in which form the 
greater proportion of ingested carbohydrate food exists, is a 
polymer of the six carbon sugar — glucose. 

Fats and lipins serve in a varied capacity in the body. 
The terms include a number of different types of sub- 
stances which may be roughly divided into two groups: fats, 
which are combinations of fatty acids and glycerol or other 
alcohols, and lipins, which resemble the fats in certain 
properties but which differ in chemical constitution. Lipins 
are substances of a fat-like nature yielding fatty acids or 
derivatives of fatty acids and some other radicle containing 
nitrogen or nitrogen and phosphorus. Of the latter group 
lecithin has been studied extensively; the other groups, such 
as complexes containing other lipins, protein, carbohydrate, 



20 N UTRITION A ND CLINIC A L DIE TE TICS 

various organic and inorganic compounds, have received little 
attention and our knowledge of their functions is limited. 
Recent investigation has indicated that the lipins are im- 
portant factors in the transportation of fat by the blood 
stream to the tissues and particularly to the mammary gland. 
The "fat" of food is a mixture of fats and lipins. 

Fats are used almost exclusively in the production of energy 
or in the regulation of temperature. In temperature regula- 
tion it functions in a two-fold manner: it yields energy in the 
form of heat as the result of oxidation, and it serves as an 
insulating medium in the form of deposited subcutaneous 
fat. Chemically considered, fats are combinations of carbon, 
hydrogen and oxygen. As contrasted with the carbohydrates, 
fat molecules contain little oxygen, and consequently yield a 
greater amount of energy upon oxidation. A gram of fat will 
yield more than twice as much energy in the form of heat as 
will a gram of carbohydrate. The body appears to prefer 
carbohydrates, however, for the production of heat, at least 
for short intervals of time. It stores its energy yielding 
material as fat; the quantity of carbohydrate stored in the 
body is comparatively small, not sufficient to last a man 
more than a day or two even when some fat and protein are 
consumed at the same time, as in fasting. 

Water and salts are concerned not only in the structure of 
the cells but in the maintenance of normal physical and chem- 
ical relations between the parts of the cells — intracellular 
water and salts — and between the groups of cells which con- 
stitute the tissues and organs of the body — extracellular 
water and salts. Water gives to the blood its fluidity, and 
this enables it to permeate the cellular structures of the body, 
carrying with it the dissolved gases and substances used in 
the activities of the cell. Suspended in the water (colloidal 
solution) are proteins and organized bodies, the blood cells. 
The salts which are dissolved in the water assist not only in 
maintaining normal osmotic conditions between all parts of 
the body, but also a uniform reaction by combining with 
acids and bases and transporting them to the lungs and 
kidneys for excretion. 

Recent work has demonstrated the presence of other sub- 
stances in food which are essential to the normal functioning 
of the body. The absence of these materials results in 
pathological changes, and the ingestion of very small amounts 
is accompanied by rapid recovery. The name "vitamines" 
has been applied to these substances by Funk. There appear 
to be at least three types: a substance soluble in fat, desig- 
nated fat-soluble A, protective against xeropthalmia ; a sub- 
stance soluble in water, designated water-soluble B, protect- 



INTRODUCTION 21 

ive against beriberi, and another water-soluble substance 
protective against scurvy. We know little of the chemical 
nature of these substances but their importance in the diet 
is, on the other hand, unquestioned. 

These, then, are the facts which underlie dietetics, and 
while they are indisputably exact, much of the success of 
feeding in disease still must rest on clinical experience; for 
given hard-and-fast scientific facts the personal equation 
always enters into the picture and it will always be true that 
certain individuals will not react to food stimuli in the logical 
way, idiosyncrasy playing a not inconsiderable role. Since 
this is true in health, how much greater must be the variation 
in disease when one considers that all people differ in their 
habits, environment, age, activity of the glands of secretion, 
and susceptibility to certain food elements, etc.? 

It is undoubtedly true that in health some people eat too 
much, this being the larger error than that they eat too little; 
on the other hand, in disease many if not most people eat too 
little and add an element of starvation to an organism already 
handicapped by functional disturbances, infections or what 
not. The crux of the matter lies in selecting a diet suited 
to the individual conditions under varying circumstances, not 
alone in quantity but in quality as well. Recent advances 
in our knowledge of the specific dynamic action of food-stuffs 
have made it easier to say what food should theoretically 
suit a certain set of circumstances and on this basis one can, 
to a certain extent, choose suitable feedings, provided the 
personal equation is not too insistent. 

In certain diseases the indications for diet are clear cut and 
are largely a matter of rule, adherence to which will usually 
bring about the result desired, e. g., in obesity, while in others 
there is no counting on the results, for the foods which suit 
conditions in one individual will fail to produce the desired 
result in another, so that while the principles remain the 
same the individual requirements may be quite different 
and opportunity is afforded for the practise of nice judgment. 
In such a disease as typhoid fever this is particularly true, 
and the best feeding results will be obtained by the medical 
attendant who gives the most attention to details and uses 
the best judgment in the selection of foods, both quantita- 
tively and qualitatively. In such conditions it is possible 
only to indicate the principles to be used in ordering foods, 
leaving the rest to the individual attendant's discretion. So 
it is throughout the entire range of disease — there must be a 
knowledge of the facts in the biochemistry of foods, com- 
bined with clinical experience and good judgment if one 
wishes the best results. 



PART I. 

FOODS AND NORMAL NUTRITION 



CHAPTER I. 
DIGESTION, ABSORPTION AND EXCRETION. 

DIGESTION 

Enzyme Action. — Food, when ingested, is, with but few 
exceptions, potential nourishment. Before it can be used in 
the body it must be reduced to simpler forms oe liberated 
from structures unavailable for absorption into the blood. 
Until food is in a condition readily to pass through the walls 
of the alimentary tract, it is not available as a factor in 
metabolism. Such transformations are accomplished in the 
processes of digestion. As the result of these, solid masses 
of food are disintegrated, insoluble carbohydrates, fat, and 
protein complexes are transformed into compounds which 
are soluble or of such size (ultramicroscopic) that they may 
readily traverse the walls of the alimentary tract and finally 
reach the blood and be carried to the various cellular struc- 
tures of the body. This conversion of heterogenous food 
masses into a pabulum of comparatively simple and uniform 
consistency is accomplished with the aid of enzymes (fer- 
ments), 1 whose activities are furthered by the mechanical 
movements of the alimentary tract. 

Enzyme action is catalytic in nature. In the presence of 
enzymes the rate of digestive activity increases. In the pres- 
ence of water or dilute solutions of alkalis or acids, the con- 
version of starch into maltose proceeds slowly. The addi- 
tion of the salivary amylase, ptyalin, to a starch mixture 
under suitable conditions of alkalinity and temperature, 
increases the rate of the process ; instead of requiring a period 
of days and weeks for the completion of the digestion of a 

1 While we will confine our discussion largely to the enzymes of the digestive 
tract, it must be remembered that enzymes are present in all tissues and fluids 
of the body. 



24 DIGESTION, ABSORPTION A ND EXCRETION 

given mass of material, a few minutes or hours suffice. These 
changes are produced, furthermore, at the comparatively low 
temperature of the body. 

Enzyme action is specific; for each kind of substance to be 
changed a special enzyme is elaborated. If many interme- 
diate products are formed, more than one enzyme may be 
required to reduce a food material to its simplest state. 
Ptyalin, the salivary amylase, can carry the digestion of 
starch only as far as the maltose stage. Another enzyme, 
maltase, is required for the cleavage of maltose in the forma- 
tion of glucose. This enzyme is restricted in its action to 
maltose and glucose; it cannot change sucrose or lactose or 
any other carbohydrate. To complete the digestion of food, 
then, many different enzymes are necessary. 

Enzymes are classified according to the types of chemical 
reactions they affect. They are named by adding the suffix 
"ase" to the type of reaction, or to the substrate, the sub- 
stance upon which they act. Practically all the enzymes of 
the digestive tract are members of the group designated as 
hydrolases. Their function is to aid in the disintegration of 
complex food molecules, changes which involve cleavages of 
the molecule with the addition of the elements of water. The 
more important digestive enzymes will be discussed in con- 
nection with the digestive processes. 

The activities of any particular kind of enzyme are influ- 
enced by its environment. Such factors as (a) reaction, (b) 
temperature, (c) concentration of the enzyme, (d) concentra- 
tion of the products of reaction, (e) presence of electrolytes 
— salts, alter the degree and intensity of enzymatic transfor- 
mations. 

For each kind of enzyme there is a degree of acidity (excess 
of hydrogen ion) or alkalinity (excess of hydroxl ion) at 
which it will produce its maximum effect. If this optimum 
concentration of hydrogen (or hydroxl) ion is not reached or 
is exceeded, the action will be retarded because of the absence 
of sufficient ions to promote the activity of the enzyme or of 
an excess of ions which would result in an inhibition or 
destruction of the enzyme. Most enzymes act best at a 
temperature between 35 and 45 C, approximately body 
temperature; they are destroyed at higher temperatures (70 
to ioo° C), and inhibited at lower temperatures. Although 
a small quantity of enzyme is capable of effecting the conver- 
sion of a large amount of food, with a greater concentration of 
enzyme the same result may be produced in a much shorter 
time, the increase in rate being in most cases approximately 
proportional to the concentration. An accumulation of the 



DIGESTION 25 

products of digestion tends to retard the speed with which 
the reaction proceeds. 1 This is in accord with the usual 
course of chemical reactions in which the products are not 
removed. They proceed in one direction until an equilibrium 
is reached between the reacting substances and the end- 
products, or until all of the reacting substances are consumed, 
when demonstrable reaction ceases; a change in the concen- 
tration of any of the factors results in a reaction which tends 
to restore the equilibrium, or cause it to go to completion. 
Certain enzymes have been shown to possess the power of 
reversibility such that they can cause a reaction to proceed 
in a direction opposite to that normally followed. Electro- 
lyte facilitates or retards enzyme activity according to the 
kind and concentration; small quantities of certain electro- 
lytes are apparently essential. 

Some enzymes when secreted from the cell are in an in- 
active form which requires the action or presence of another 
substance or enzyme before they become active. Such 
enzymes are called zymogens, or mother substances, and the 
activation is caused by a zymo-exciter or kinase. For ex- 
ample, the activation of the zymogen, pepsinogen, is caused 
by the zymo-exciter hydrochloric acid and that of the zymo- 
gen, trypsinogen, by the kinase, enterokinase. 

Oral Digestion.— In the mouth the physical activities of 
the alimentary tract predominate over the chemical. Here, 
through mastication, the food is finely divided and thor- 
oughly mixed with the salivary secretion. Three results are 
accomplished. By fine division the food is prepared for the 
subsequent action of the digestive juices. By the admixture 
of water and mucus dry and hard food masses are moistened 
and softened and swallowing is facilitated. The salivary 
amylase, ptyalin, is brought into intimate contact with the 
food and thus amylolytic digestion is promoted. Food re- 
mains for so short a time in the mouth that relatively very 
little digestion occurs there. Thorough mastication of food 
affects the digestion and consumption of food, aside from the 
chemical activities of salivary digestion. An increased flow 
of appetite juice results from the prolonged stimulation of 
the taste organs of the mouth. A decreased food consump- 
tion results in part from a developing sense of satiety and in 
part from fatigue of the muscles of mastication. Thorough 
chewing also prepares the food for complete digestion in the 
stomach and intestines — including salivary 1 digestion in the 

1 In the ordinary course of digestion, particularly in the intestines, the end- 
products are removed by absorption so that hydrolysis is facilitated rather than 
retarded, 



26 DIGESTION, A BSORP TION A ND EXCRE TION 

stomach. The function of saliva has been held by certain 
investigators to be primarily that of a lubricant in swallow- 
ing. The fact that the saliva of certain animals, particu- 
larly carnivora, contains no amylase or other enzymes and 
that in aquatic mammals there is apparently no salivary 
secretion of importance, are cited as proof of that inference. 
We shall see, however, that for man the digestive function 
of saliva is desirable although probably not essential. 

The quantity and quality of saliva secreted has been shown 
to vary with the nature of food ingested; coarse (dry), granu- 
lar, or acid food elicits the production of a thin, watery flow 
of saliva, while moist foods stimulate the flow of a more 
viscid secretion. The amount of saliva secreted is affected by 
the sight or smell of food, it is stimulated by appetizing food 
and inhibited by non-appetizing food. The total daily ex- 
cretion is estimated at 1500 cubic centimeters, 50 ounces. 

The chemical constituents of saliva are principally water, 
mucin, inorganic salts — phosphates, chlorides, sulphates and 
carbonates and traces of thiocyanates, nitrites — and enzymes. 
Saliva is slightly alkaline to almost neutral in reaction, hydro- 
gen-ion concentration 2-4 x 10- 8 , approximately that of 
blood. The reaction fluctuates slightly with changes in the 
acid-base equilibrium of the blood. A slightly acid saliva, 
2 x 10- 7 gram molecules of hydrogen-ion, has been observed 
to flow from the salivary glands, particularly in association 
with acidosis. An acid, mixed saliva is obtained from the 
mouths of some individuals. In the latter case the acidity 
is often the result of fermentation (bacterial) of food debris 
on and between the teeth. 

Salivary digestion is confined almost entirely to the trans- 
formation of starch and dextrins ; cellulose is not attacked by 
it. Salivary amylase, or ptyalin, is the principal enzyme in 
the saliva of man. Through its action insoluble or colloidal 
starch is converted into soluble and diffusible maltose and 
this, through the action of maltase present in the saliva and 
also in the intestines, is changed to glucose. The reaction 
best suited for the activity of salivary amylase is neutral to 
slightly acid, a hydrogen-ion concentration of 2 x 10- 7 , has 
been found to be the optimum reaction; the presence of even 
a slight excess of acid inhibits its action. Protein combines 
with acid and the resulting compound is not sufficiently acid 
to prevent the action of salivary amylase. 

Starch digestion continues for some time after the food has 
reached the stomach — half an hour or longer, according to 
the quantity and nature of the food ingested. This is par- 
ticularly true in the case of solid food because of the thorough 






DIGESTION 27 

mixing of food and saliva in the mouth and the collection of 
food in the fundus of the stomach. Furthermore, when pro- 
tein is ingested with starch it combines with the acid of the 
stomach and for a time a reaction is maintained in the food 
mass which is suitable for the activity of salivary amylase. 
That amylolytic digestion in the stomach is desirable is indi- 
cated by the fact that protein food mixed with starch when 
subjected to the action of saliva has been shown to digest 
more rapidly with gastric juice than when not so mixed. 
This increased digestibility has been found to be due to physi- 
cal changes in the starch. Boiled colloidal starch absorbs 
pepsin and thus inhibits its action. If, however, the starch 
be changed to its soluble form through the action of salivary 
amylase, the activity of pepsin is unaffected. Thus salivary 
digestion of starch is an important aid to active gastric 
digestion. 

Gastric Digestion. — The stomach serves as a reservoir in 
which the food masses accumulate, are thoroughly mixed, 
acidified, partially digested, and passed on in small quanti- 
ties to the intestines for further digestion and absorption. 
Milk is coagulated in the stomach at the beginning of its 
digestion. Very little absorption of food material takes 
place in the stomach. 

The resting empty stomach is practically collapsed. The 
fundus or cardiac portion of the stomach is in a sense a reser- 
voir which accommodates itself to the size of the entering 
material. As additional masses of food are passed into the 
stomach, the preexisting material is forced forward and to 
one side in such a way that the last portions of swallowed 
food are, in general, received within the mass already present 
in the stomach. Gastric juice is then secreted upon the sur- 
face of the solid contents of the stomach and, in the fundus, 
digestion proceeds from the surface toward the center. The 
partially liquefied products are forced to the pyloric portion 
of the stomach by the tonic contractions of the stomach walls 
for acidification, further digestion and passage to the intes- 
tine. The tonic contraction of the stomach is not a steadily 
increased tension, but appears as tonus waves of from one 
to three minutes duration. As the stomach gradually 
empties, and when the stomach is empty, these waves pass 
into the hunger contractions of the empty organ. This 
arrangement and sequence of events permit of rather extensive 
salivary digestion in the center of the solid food masses in 
the'stomach. The processes described above apply particul- 
arly J:o the more solid foods. Liquid or semisolid foods do 
not necessarily follow such a course. 



28 DIGESTION, ABSORPTION AND EXCRETION 

The walls of the fundus of the stomach are in a continual 
state of contraction and force the food forward by steady 
pressure. The pyloric portion of the stomach, in contrast 
with the fundus, is in active motion; contraction waves pass 
from the fundus toward the pylorus carrying some of the 
food mixture before them and against the closed pylorus. 
While the pylorus remains closed the material is not only 
carried forward by these waves but is also returned through 
the advancing rings of contracted muscles. 

Through the mixing of the food and the digestive action 
the heterogeneous food mass is converted into the liquid or 
finely divided semiliquid chyme. The addition of gastric 
juice increases the acidity of the mass. According to Cannon 
the pylorus is caused to open primarily by the acidity (true 
or hydrogen-ion concentration) of the chyme forced against 
it. Hence when the acidity is sufficiently great, the pylorus 
opens and a portion of the acidified food is forced into the 
small intestine. The presence of acid in the intestine causes 
the pylorus to close and remain so until the acid forced into 
it is neutralized and the chyme in the stomach is again acid 
enough to cause the pylorus to open. Carlson's recent work on 
man has led him to question the acid control of the pylorus, 
especially from the stomach side. He found that in normal 
man and animals there is a correlation between the opening 
of the pylorus and the tonus rythmn of the fundus of the 
stomach in such a way that the pylorus opens at the height 
or near the end of each tonus wave. This co-ordination is 
relatively independent of the chemical reaction of the stom- 
ach. In a normal person a certain degree of acidity or of 
alkalinity or complete neutrality on the stomach side of the 
pylorus is compatible with normal pyloric rhythm. Under 
all conditions acid acting on the duodenal side of the pylorus 
never fails to introduce reflex contractions of the pyloric 
sphincter, even after the resection of all extrinsic nerves to 
the pylorus. Hard particles of food may temporarily pre- 
vent the opening of the pylorus, and as we shall see later, 
certain material, particularly some of the liquid foods, may 
pass the pylorus without being acidified. Later in the pro- 
cess of digestion the pylorus permits even comparatively 
large masses of undigested food and indigestible material to 
pass into the intestines. 

For liquids the processes just described do not always 
occur. When water is taken, even on a full stomach, it 
passes through into the intestines in a comparatively short 
time and without becoming acid in reaction. Examination 
of men and animals with the radiograph, and studies of the 



DIGESTION 29 

structure of the stomach and of the arrangement of its con- 
tents, have shown that water, in passing through the stomach, 
follows the lesser curvature of the stomach. Raw white of 
egg also passes through the stomach without becoming acidi- 
fied. 

Milk is usually coagulated as soon as it enters the stomach; 
it has been shown, however, that during the early days of 
infancy, milk may pass directly into the intestines without 
becoming acidified or coagulated. Experiments with semi- 
solid foods and with milk have shown that when such foods 
do not pass directly into the intestines, the greater portion of 
the water and dissolved matter pass on and the more solid 
foods remain behind for digestion. Thus two portions of 
food containing the same amount of solid material, but one 
having a greater proportion of water than the other, will 
require practically the same time for digestion and passage 
out of the stomach. 

Aside from effecting mechanical mixture, the gastric pro- 
cesses are essentially proteolytic in effect. A milk-coagulat- 
ing enzyme, rennin, and a lipase are also present, both of 
which are important under special conditions— rennin when 
milk is taken and lipase when finely divided, emulsified, fats 
are ingested. Carbohydrates are undoubtedly hydrolyzed 
by hydrochloric acid, the extent depending upon the concen- 
tration of the acid and the time it has to act. Such action is, 
however, under ordinary conditions, very slight. An exces- 
sive concentration of acid in the stomach, whether it be 
unneutralized appetite juice, ingested acid or the presence 
of fat, is usually accompanied by a regurgitation of material 
from the duodenum. This regurgitated material tends, by 
neutralization, to reduce the acidity of the gastric contents. 
It has been suggested that such regurgitation is a normal 
mechanism by means of which the reaction of the gastric 
contents is maintained at the optimum reaction for the 
activity of the gastric enzymes. In the regurgitated ma- 
terial are the enzymes of the pancreatic and intestinal juices 
and also bile. The extent of the activity of these substances 
in gastric digestion is not known. The most important 
chemical factors in gastric digestion are, then, the enzymes 
— pepsin, rennin and lipase — and hydrochloric acid. The 
salts present are important aids to digestive activity. 

Pepsin (gastric protease) is secreted as pepsinogen from all 
parts of the gastric mucosa. The hydrochloric acid in gas- 
tric juice changes pepsinogen into pepsin and produces an 
acidity favorable for the accelerating action of pepsin. Carl- 
son has found that the average normal person secretes from 



30 DIGESTION, ABSORPTION AND EXCRETION 

600 to 700 c.c. of gastric juice on the average palatable meal, 
or about 1,500 c.c. per day. This secretion corresponds to 
240 to 250 milligrams of pepsin per dinner; capable of digest- 
ing 630 to 750 grams of protein in three hours. The total 
pepsin secreted in twenty-four hours is capable of digesting 
one and one-half kilograms of coagulated egg white in three 
hours. These amounts are far in excess of the needs of 
digestion, which may explain the clinical findings of a great 
reduction in pepsin content without evidence of impaired 
gastric digestion. 

Hydrochloric acid is secreted chiefly in the fundus of the 
stomach; its concentration when freshly secreted is from 
0.45 to 0.55 per cent., expressed clinically, 120 to 130. The 
acidity of the gastric juice is dependent upon the rate of 
secretion. With rapid secretion the maximum acidity is 
obtained, while juice secreted at a slow rate has a lower 
acidity. The low acidity sometimes ascribed to gastric juice 
0.2 per cent., or 40 to 50 expressed clinically, is the acidity of 
the contents of the empty stomach and represents the con- 
tinuous secretion plus swallowed saliva and the occasional 
admixture of intestinal contents. According to Carlson, 
there is no type of deviation from the normal in which the 
gastric glands are capable of secreting juice greater than 
normal acidity. There may be hyposecretion but no physi- 
ological hypersecretion. Deviations of acidity from the 
normal may occur but they are always in the direction of 
hypoacidity down to anacidity. The clinical hyperacidity 
is, then, apparently a symptom and not a cause of this 
syndrome. The optimum acidity for peptic action is about 
0.2 to 0.5 per cent, of hydrochloric acid or in terms of hydro- 
gen-ion concentration, between 1 x 10- 5 to 4 x 10- 3 gram 
molecules of hydrogen-ion. The acidity of the gastric con- 
tents varies during the course of digestion, normally increas- 
ing gradually to a maximum and then decreasing somewhat. 
Hawk has found the variations of the acidity of the gastric 
contents following a test meal when determined from hour 
to hour to be characteristic of certain diseases. Fluctuations 
occur in the acidity with variations in the relative amount of 
associated substances, particularly proteins, that combine 
with acid. 

Through the action of hydrochloric acid and pepsin some 
solid protein materials are first swollen. This swollen pro- 
tein, together with the remaining protein material, is then 
broken down into simpler protein complexes, the proteoses 
and peptones. If the action be sufficiently prolonged arti- 
ficially, pepsin may hydrolyze protein to the simplest protein 



APPETITE . 31 

products, amino-acids, but in the body in the time during 
which protein ordinarily remains in the stomach, digestion 
proceeds to the proteose and peptone stages. Pepsin facili- 
tates the digestion of all proteins with the exception of kera- 
tin. While peptic digestion may not be complete in the 
chemical sense, it prepares the protein material for further 
digestion in the intestine. This is particularly true of colla- 
gen in connective tissue which permeates all animal: parts. 
Collagen is swollen and partially hydrated in the stomach, 
an essential process for its subsequent digestion by the pro- 
teolytic enzyme of the pancreatic juice, trypsin. As the 
result of peptic digestion, then, solid protein masses of food 
are disintegrated into smaller particles, and "peptonized," 
wholly or in part, forming a thin soupy mass which is readily 
passed on to the intestines. 

Fatty material is warmed by the stomach and, with the 
exception of the very solid fats, melted, the connective mem- 
branes of the fatty tissue are digested and the fat liberated, 
and thus it is prepared for digestion in the intestines. Finely 
emulsified fats, e. g. f cream, egg yolk, etc., are acted upon 
by gastric lipase and hydrolyzed into fatty acids and gly- 
cerol; such action is, however, of little practical importance. 
Since salivary digestion is stopped by the presence of 
"free" hydrochloric acid, carbohydrate digestion ceases as 
soon as the stomach contents become distinctly acid. 

The caseinogen of milk is transformed by rennin into 
insoluble casein, which forms a clot. In the formation of 
the clot fat and other substances present in milk are entangled 
and held in the stomach with the casein. It has been shown 
that the watery portion of milk, whey, passes on quite rapidly 
into the intestines and that the solids (casein clot) are re- 
tained for digestion. This coagulative process permits 
the ingestion of a highly nutritious liquid without burdening 
the intestine with large quantities of complex undigested 
protein material. For a further discussion of rennin, see 
Milk, p. 150. 

Appetite. — Appetite is an important factor in digestion ; 
that this is true is particularly evident in the case of gastric 
secretion and digestion, and the subsequent digestive pro- 
cesses. True gastric juice is secreted continuously even 
in the absence of food or obvious nervous excitatory factors, 
in quantities varying from a few cubic centimeters to 150 
c. c. per hour, average 30 to 60 c. c. per hour. This secretion 
is usually lower in acid than the appetite secretion. It 
is not markedly increased in prolonged starvation and is 
decreased and may be entirely absent in fevers and various 



32 DIGESTION, A BSORP TION A ND EXCRE TION 

types of gastritis. Two particular types of stimuli increase 
the rate of secretion of gastric juice, psychical and chemical. 
The sight, thought, smell, or taste of food, or familiar sounds 
associated with food or its preparation will produce a flow 
of gastric juice. 1 This juice is highly acid in character 
and has a strong digestive power. It is designated "ap- 
petite juice" and is the result of nervous stimulation of the 
gastric glands. The flow of appetite juice appears upon 
the mastication of food and begins to decline at the end of 
a meal when the taste of food has disappeared from the mouth. 
The rate of secretion is from 1.5 to 12 c. c. per minute, 
average about 3.5 c. c. per minute. This secretion is absent 
in normal infants. It is gradually diminished or absent in 
gastritis or any inflamatory condition of the gastric mucosa, 
in fevers and in strong emotions of anger or pain. Stom- 
achics or bitters have little or no effect in stimulating the 
flow of appetite juice. A flow of appetite juice is important 
but not essential. Adequate digestion of food has been 
observed in the absence of appetite juice in (a) normal 
infants and (b) under experimental conditions in animals 
and man when food is introduced directly into the stomach 
and (c) the complete digestion of unpalatable food by both 
man and animals. Under such conditions a flow of gastric 
gastric juice is stimulated through chemical means. The 
composition of "appetite juice" has been shown by Povlov 
to be approximately the same in quality regardless of the 
nature of the diet ingested; it varies in amount according 
to the extent and nature of the appetite stimulus. 

Secretion of gastric juice under the influence of chemical 
stimulation is varied: bread produces a copious flow of 
juice with a greater digestive capacity than meat; fats and 
alkalis in low concentration inhibit the flow of gastric juice; 
alkali in higher concentration may cause an increased flow 
of gastric juice. The apparent specific effects of foods are 
probably the result of variation in the degree of stimulation 
resulting from the extractives and digestive products con- 
tained in the food or produced by digestion. This stimu- 
lation is probably excited through liberation of a gastric 
hormone. The importance of a secretion of appetite juice 
is, then, evident, for, in the case of food substances, which 
are not in themselves "chemical" stimulants, products of 
digestion obtained under the influence of the psychical 
stimulation become the chemical stimulants of the gastric 

Similar and readily recognizable phenomena occur in the secretion of saliva* 
the "mouth waters" at the thought, sight, or smell of appetizing food, while 
unpalatable food does not have this effect. 



APPETITE 33 

secretion which carries on the digestive process after that 
induced by nervous stimulation has ceased. 

Appetite has a secondary effect upon the flow of pancreatic 
juice, for this is in large measure related to the flow of gas- 
tric juice. Acid from the gastric mixture in the duodenum 
produces the hormone, or "chemical messenger" called 
secretin from an inactive mother substance: prosecretin. 1 
Secretin is carried in the blood and. lymph to the pancreas 
and intestinal glands where it stimulates the flow of the 
pancreatic and intestinal juices, and to the liver where it 
stimulates a flow of bile. The flow of pancreatic juice is 
also affected by nervous stimuli. The indirect effect of 
lack of appetite is a slowing of all digestive processes. A 
good appetite becomes, then, a most important factor in 
digestion. After suitable preparation food is more readily 
digested. 

Appetite is not to be confused with hunger — it is an en- 
tirely pleasant state of consciousness associated with our 
memories of food, particularly the taste, sight and smell of 
food, hunger is a sensation of pain. Appetite may exist 
without hunger and is apparently a matter of individual ex- 
perience which may be modified by experience. It is not a 
certain guide to the wholesomeness or nutritive value of 
food — particularly when food is modified by modern pro- 
cesses of manufacture in which certain important food 
factors may be removed, as in milling, purification, etc. 
There has been some recent evidence to the effect that 
animals allowed to choose their food from a number of foods 
will choose the diet best suited to their needs — but this is 
not entirely a proven fact. For man, particularly, this 
does not necessarily hold for his tastes are more often affected 
by the method of cooking and the manner of serving. 

The appetite is stimulated or depressed by the manner in 
which food is prepared, the way in which it is served and by 
the mental state of the individual concerned. Food properly 
cooked, well seasoned and attractively served tends to 
stimulate the appetite, whereas undercooked or overcooked 
food served in a careless manner does not stimulate the 
appetite and may even create a dislike for the food. The 
determination of what constitutes a well-cooked and attrac- 
tively served meal rests to a large degree with the taste and 

1 A hormone is a specific chemical substance produced, under a definite stimulus, 
in one organ which passes in the circulating blood and lymph to another organ 
in which it excites a secretion or change characteristic of- that organ. The 
quantity of secretion or action produced is related directly to the quantity of 
hormone formed; a distinction from enzymes. Hormones are comparatively 
simple chemical substances, diffusible, heat stable, and readily oxidized. 

.1 



34 DIGESTION, ABSORPTION AND EXCRETION 

habits of the one who is to eat it. Food which is properly 
cooked for one person may be unfit to eat in the estimation 
of another. Likewise, attractive service is purely a relative 
term. An illustration of the varied tastes of individuals 
and even peoples is evident from a consideration of the 
diets of different countries and even in the same country. 
The mental state of the individual as affected by pleasure, 
worry, excitement, pain or disappointment, also tends to 
stimulate or depress the appetite. Appetite is not, however, 
an absolute necessity for complete and ready digestion of 
food, for it has been shown that food which was actually 
distasteful to the person eating it was just as completely 
digested and utilized as food which was eaten with a relish. 

Hunger. 1 — The sensations of hunger have been held to 
originate through various sources, among them the lack of 
food substances in the blood or tissues, to the stimulation 
of the nerves of the stomach by an accumulation of gastric 
juice in the secreting cells and to a stimulation of the nerves 
of the mucous membrane of the stomach. Cannon has 
shown, and Carlson has further confirmed the fact, that 
the sensation of hunger is in its most important components, 
due to a type of contractions of the empty or nearly empty 
stomach, which are not directly related to the immediate 
needs of the body for nutrient material. 

The term empty stomach is a relative one for there is 
usually some gastric juice, saliva or duodenal contents 
present (25 to 50 c.c). The empty stomach in healthy indi- 
viduals, is never completely at rest but, in general, exhibits 
a greater degree of tonus than the full stomach. At the 
height of digestion the contractions of the stomach begin 
in the lower portion of the stomach and involve only the 
antrum, as the stomach empties these digestion contractions 
start further and further up the body of the stomach until 
they finally begin at or near the cardiac end when the stomach 
is nearly or completely empty of food. The chief difference 
between digestion contractions and hunger contractions is, 
then, in the greater vigor of the empty stomach, the involve- 
ment of the entire stomach and the effect of the contractions 
upon the consciousness. The contractions of the empty 
stomach come in periods varying from fifteen minutes to an 
hour — sometimes longer — characterized by a gradual increase 
in tonus and on these tonus waves are superimposed a series 
of rapid contractions each lasting from eighteen to thirty sec- 

1 Much of this discussion of hunger is based on a lecture given by Lt.-Col. A. J. 
Carlson to the Section of Food and Nutrition, Surgeon General's Office, U. S. 
Army. 



INTESTINAL DIGESTION 35 

onds and increasing in intensity until at the end an incomplete 
tetanus may result lasting from two minutes up to fifteen 
minutes. This latter condition is followed by a period of 
relative quiescence for from a half hour to several hours. 

The contractions of the stomach just described give rise, 
in the normal person at least, to the varied degrees of pres- 
sure, pain and emptiness which we associate with or call 
hunger. The sensations associated with hunger such as 
nervousness, headache, and feeling of weakness and dizzi- 
ness and even fainting, are largely of reflex origin involving 
stimulation of nerves in the muscular coats of the stomach 
by the strong hunger contractions. In sick individuals or 
a person suffering from neurosis, or in prolonged starvation 
the effect of the contractions upon the consciousness may 
give rise to other effects such as the feeling of sick stomach, 
nausea, or of general epigastric distress. It is the gastric 
contractions which give rise to the sensation of hunger and 
not the central consciousness of hunger which induce the 
contractions. Hunger is a type of muscle sense for the 
sensations are due to the stimulations of the nerve-endings 
in the muscular coats of the stomach. In general, the 
presence or absence of hunger contractions parallel the call 
for or refusal of food. 

Hunger contractions decrease with age; they are at 
their maximum in early life. They persist or even increase 
in prolonged starvation, although in the later stages of 
starvation mental depression and other central changes may 
lead to alteration in the conscious effects, such as nausea 
or epigastric distress. In disease the hunger contractions 
are increased in diabetes and decreased in most fevers, in- 
cluding thermic or heat prostration. 

The control of hunger, therefore, lies in the control of 
the emptying of the stomach and of the contractions of the 
empty or nearly empty stomach. Disturbances of gastric 
motility, in vagi conductions or in parts of the nervous sys- 
tem concerned with the elaboration of the conscious sensa- 
tion of hunger will interfere with the mechanism. There 
does not appear to be any certain way to increase hunger 
except through physical work or external cold — with the 
accompanying increase in body metabolism. The various 
stomachics or bitters, long in use to improve hunger, have 
no effect when given in therapeutic doses into the stomach 
(fistula). When given by mouth such substances inhibit 
or depress the hunger mechanism in proportion to the bitter 
taste or strong stimulation of the nerve endings of the mouth. 

Intestinal Digestion. — The digestion of food which has 
been started in the mouth and stomach is completed in the 



36 DIGESTION, A BSORP TION A ND EXCRE TION 

small intestine. The pancreatic and intestinal juices con- 
tain enzymes which accelerate the transformation of all 
three of the principal food-stuffs into soluble and diffusible 
products. The action of these enzymes is facilitated by bile. 

Carbohydrates are changed into monosaccharides. Starch 
is hydrolyzed into maltose by the pancreatic amylase or 
amylopsin, and into glucose by the enzyme maltase. The 
sugars, maltose, sucrose, and lactose, are broken down into 
fructose and glucose, and galactose and glucose respectively 
by maltase, sucrase and lactase. Unaltered protein with 
the exception of unhydrated collagen and keratin, and the pro- 
ducts of peptic digestion are transformed into amino-acids 
by the trypsin present in the pancreatic juice and erepsin 
contained in the intestinal juice. 

Erepsin, the protease of the intestinal juice, secreted from 
glands in the intestinal mucosa, acts chiefly upon peptone 
and peptides, transforming them into amino-acids, thus 
completing the digestion of protein which has been started 
by pepsin and trypsin. Erepsin does not digest natural 
complex proteins, with the exception of caseinogen, his- 
tones and protamines. Enterokinase, another intestinal 
enzyme, is an activating enzyme which is capable of chang- 
ing trypsinogen into trypsin. 

Nucleoproteins are only partially digested by pepsin and 
trypsin; their digestion is completed by special enzymes 
contained in the intestinal juice and in the walls of the intes- 
tines. Fats are emulsified in the intestines in the presence 
of soaps and hydrolyzed into fatty acids and glycerol by the 
pancreatic lipase, steapsin. Bile also aids in the digestion 
of fat by increasing the solubility of the soaps and fatty 
acids; and by accelerating the action of the lipase. Bile 
contains no enzymes of importance. 

The most favorable condition for intestinal digestion is in 
a neutral to slightly alkaline medium. The pancreatic juice 
is alkaline in reaction equivalent to approximately 0.5 per 
cent. Na 2 C0 3 . It has a hydrogen-ion concentration of about 
2 x 10- 8 gram molecules per liter. 

The structure and movements of the intestines facilitate 
digestion and absorption but do not enable them to hold 
large quantities of food. Small quantities of chyme are 
received from the stomach as often as conditions in the 
stomach and intestines are suitable for its transference; in 
general, when the acid chyme passed into the intestine be- 
comes practically neutral. The reciprocal action between 
the two organs prevents overloading of the intestines with 
large quantities of acid material. 



SENSIBILITY OF ALIMENTARY CANAL 37 

The movements of the intestines have been described by 
Cannon after examination, with rontgen rays, of the intes- 
tines of a cat fed with food mixed with bismuth subnitrate. 
He found that food masses passed from the stomach were 
collected together in the duodenum, mixed with pancreatic 
and intestinal juices and bile, and moved along the intes- 
tines in a continuous column. After the food mass had been 
carried for a short distance, the forward movement stopped 
and the solid column was broken up into short segments by 
a number of constrictions in the intestinal wall. These 
segments were again divided, the halves of two adjacent 
segments forming a new one. In this way the food masses 
were repeatedly divided without a forward movement of 
the total mass. After a time the material was moved along 
as a continuous column, as before, to another portion of the 
intestine where segmentation again took place. By this 
means the intestinal juices are thoroughly mixed with the 
chyme, the enzymes have the maximum opportunity to act 
and the food is brought into intimate contact with the walls, 
of the intestines, thus facilitating digestion and absorption. 

Sensibility of the Alimentary Canal. — The sensations 
associated with the alimentary canal which influence con- 
sciousness in normal persons are (a) hunger, (b) appetite, 
(c) satiety, (d) fullness, (e) defecation urge, and (/) peculiar 
sensations of heat that may follow strong chemical stimu- 
lation of the gastro-intestinal mucosa. In persons with 
gastro-intestinal disorders we may have (a) nausea, (b) 
anorexia, (c) bulimia, (d) pains of peptic ulcer, (e) pains of 
gastralis, (/) pains of gastro-intestinal colic or cramp, gas 
pains, and (g) ill defined and not definitely localized general 
discomfort or tension referred to the viscera frequently ex- 
perienced in mild gastritis, enteritis, and constipation. In 
addition to these recognized sensations there are undoubtedly 
other sensory components which affect only the reflex or 
subconscious processes. There does not appear to be any 
tactile sensibility of the mucosa of the alimentary tract. 
Temperature sensibility exists in the esophageal, gastric, 
and anal mucosa and possibly to a less extent in the intesti- 
nal mucosa for both heat and cold but which is much less 
delicate than that of the skin. The gastro-intestinal mu- 
cosa appears to be entirely devoid of pain nerve endings. 

The sensation of warmth or heat experienced when tak- 
ing strong acids or concentrated alcohol into the stomach 
may be due to stimulation of heat nerve-endings in the 
mucosa. Weaker chemical stimuli such as cold water or 
very weak alcohol produce an effect on the consciousness 



38 DIGESTION, A BSORPTION A ND EXCRE TION 

similar to, if not identical with, the sensation of appetite. It 
is evident, therefore, that moderate chemical stimulation 
contributes to the element of appetite. Such sensations 
may originate from various substances in the food. This 
gastric component of appetite is not ordinarily recognized 
when food is eaten in the ordinary way because of the more 
powerful stimuli produced by tasting, seeing or smelling 
palatable food. 



ABSORPTION 

Absorption of the products of digestion takes place largely 
in the intestines. The mucous membrane of the mouth ex- 
hibits absorptive powers, but the short time food remains in 
the mouth precludes any extensive absorption. In the 
stomach soluble food and the products of digestion are un- 
doubtedly absorbed to a certain extent, but again absorp- 
tion is so slight as compared with intestinal absorption as 
to have no practical value. A considerable degree of gastric 
absorption has been demonstrated, however, for water, 
salts, and alcohol. Absorption is stimulated by condiments. 

The maximum absorption of digestive products takes 
place in the small intestine: in the duodenum and the jeju- 
num. Normally the absorption of food products in the 
small intestine is fairly complete and consequently in the 
large intestine there is relatively little absorption; and this 
is limited chiefly to water. Under certain conditions, as in 
rectal feeding, the large intestine appears to be capable of a 
considerable absorption of food products. 

Attempts to correlate intestinal absorption with the known 
laws of diffusion and osmosis have failed to account entirely 
for the apparently selective absorptive powers of the mucous 
membranes. Since a dead membrane does follow these 
laws it has been suggested that certain "vital" forces are 
concerned. When we are fully conversant with the physico- 
chemic structures of the cell, it may be found that these 
apparently " vital" phenomena are due to special adapta- 
tions of simple laws of solutions and diffusion modified by 
the colloidal state of the substances present. 

The manner and form of absorption of protein or its prod- 
ucts are subjects of considerable controversy. Protein may 
be broken down in the processes of digestion into amino- 
acids and simple complexes of these, polypeptides. It was 
formerly supposed that protein material was absorbed either 
unchanged or as a proteoses or peptone, and converted into 



ABSORPTION . 39 

blood protein or destroyed. This view was based largely 
upon the fact that it was impossible to detect the presence 
of amino-acids in digestive mixtures or in the blood. Refine- 
ment of the methods of analysis and more careful investi- 
gation have shown conclusively, however, that digestion of 
protein proceeds beyond the peptone stage and that pro- 
tein is probably transformed almost entirely into amino- 
acids. This is in many ways the more logical conclusion, 
since there are a number of cell and tissue proteins which 
contain different proportions of amino-acids than do the 
food proteins, and these are undoubtedly arranged after 
their absorption in a different manner in the various protein 
molecules in the cells and tissues. The absorption of amino- 
acids and their simple complexes through the intestinal 
wall is more readily understood than that of colloidal pro- 
tein structures, because the amino-acids are diffusible. 

Two views with regard to the way in which these simple 
products of protein hydrolysis are carried in the blood have 
received the most consideration: (a) that the amino-acids 
in their passage through the intestinal wall are resynthetized 
into protein material, principally serum albumin or serum 
globulin, and are carried in this form by the blood to the 
cells for use in the processes of repair and growth or deami- 
nized; (b) that the absorbed amino-acids are carried by the 
blood to the various cells in the body and used directly by 
the cells or destroyed either there or in the liver. The first 
conception is probably incorrect; it was based, in part, 
upon the fact that the products of protein digestion had not 
been found in the portal blood, and on the presence of large 
quantities of ammonia in blood coming from the region of 
the intestines. According to this theory at least a partial 
disintegration of the nutrient serum proteins into simpler 
forms was necessary before they could be of use in the struc- 
ture of the qualitatively different muscle and organ pro- 
teins. The excess of simpler forms, e. g., amino-acids, re- 
maining after the formation of such more or less specific 
protein structures from the heterogeneous mass of structural 
forms presented were supposed to be deaminized in the in- 
testinal wall or possibly in the blood. The carbon moiety, 
or mass of ammo-acid material minus the animo radicle, 
was either oxidized as are the fats and carbohydrates, or 
synthetized to carbohydrates or possibly fats. The nitro- 
gen appeared as ammonium salts which were transformed 
by the liver into urea. 

The second theory is based upon recent investigations 
which have demonstrated quite conclusively that considerable 



40 DIGESTION, ABSORPTION AND EXCRETION 

quantities of amino-acids are present in the blood of the 
portal vein and in the blood and tissues in general, and that 
the ammonia of the portal blood is not chiefly the result of 
deaminization in the small intestine but originates in the 
large intestine as the result of putrefactive processes. In 
the light of these investigations opinion with respect to the 
fate of the absorbed amino-acids and simple peptides has 
changed. Instead of being either synthetized into protein 
material during their passage through the intestinal wall or 
destroyed, a part, if not all, of the amino-acids is now be- 
lieved to be absorbed into the blood stream without change. 
These simple digestive products are carried in the blood 
and lymph and taken up by the tissues for use in the general 
processes of repair and growth. The excess is deaminized, 
the amino radicle is transformed into urea, chiefly in the 
liver, partially in the muscles, while the carbon moiety is 
oxidized or used in the formation of carbohydrates or fat. 

Carbohydrates are normally absorbed as simple sugars, 
monosaccharides. Of these glucose predominates, since it 
is the end-product of the digestion of starch and maltose, 
and constitutes half of the yield from the molecule of suc- 
rose and lactose. Fructose and galatose are converted 
either in the intestinal wall or in the liver into glucose, the 
carbohydrate characteristic of the body. These carbohy- 
drates pass in the portal blood stream to the liver. This 
organ acts as a storehouse and regulator of the supply of 
carbohydrate used in the body. The normal glucose con- 
tent of the blood is approximately o.i per cent. The blood 
from the intestines during digestion, however, contains more 
than this amount. Under ordinary circumstances the liver 
removes this excess of glucose and transforms and stores it 
as glycogen. When the glucose content of the blood entering 
the liver falls below the normal amount, it receives sufficient 
glucose to keep this value constant. 

When readily absorbable carbohydrates, such as sucrose, 
maltose, or lactose, are ingested in excess, they may be 
absorbed unchanged. But the blood apparently does not 
contain an enzyme capable of hydrolyzing or utilizing suc- 
rose or lactose, for they are treated as foreign substances 
in the blood and are removed by the kidneys. Maltose, 
however, may be utilized by the tissues to a certain extent; 
excess quantities are excreted. When glucose appears in 
the blood in amounts greater than normal or which exceed 
the threshold value of the kidney it appears in the urine. 
Such conditions exist in certain diseases such as diabetes 
and may also result from the rapid absorption of glucose 



ABSORPTION 41 

from the intestines in quantities so great that the liver 
cannot take care of it. 

The appearance of sugars in the urine following too rapid 
absorption from the intestine is called " alimentary glycos- 
uria, " The quantity of any sugar which can be ingested 
without causing alimentary glycosuria is termed the assimi- 
lation limit, and is more or less specific for each sugar. Tay- 
lor holds that there is apparently no limit, beyond the capac- 
ity of the individual to retain it, to the quantity of glucose 
which may be ingested and absorbed. Some of his subjects 
took as much as 500 grams of glucose at one time without 
eliminating sugar in the urine; the limit of others was lower 
than this. Since starch requires a longer time for digestion 
the absorption of the resultant glucose extends over a longer 
period of time. With such a gradual absorption glucose 
does not normally appear in the blood in concentrations 
which will result in an alimentary glycosuria. 

Glucose is used in the body, particularly in the muscles, 
for the production of energy. One of the intermediate prod- 
ucts appears to be lactic acid, which, upon further oxidation, 
gives carbon dioxide and water, which are excreted. Carbo- 
hydrates ingested in amounts more than sufficient to main- 
tain the stores of glycogen in the liver and muscles and for 
the ordinary oxidative processes may be transformed into 
fat. Careful experiments have been conducted to prove 
this, for in spite of the general evidence obtained from feed- 
ing herbivorous animals, the formation of fat from carbo- 
hydrates has been questioned. By determining that a 
greater amount of fat was deposited in the body or excreted 
in milk than was contained in the food fed or could have 
been formed from the protein, it has been demonstrated 
quite conclusively that carbohydrates are used by the body 
in the formation of fat; careful respiration experiments 
have also shown this. 

Ingested fat is transformed in the intestines into fatty 
acids, soaps, and glycerol and absorbed in these forms. In 
their passage through the intestinal mucosa these products 
are resynthetized into neutral fats. Instead of passing 
directly into the blood through the capillaries of the intes- 
tines, as do the carbohydrates and the greater part of the 
protein digestion products, fat is taken up by the lymph 
ducts and poured into the blood stream with the thoracic 
lymph. It has been shown that fat-like substances such 
as petroleum (hydrocarbon) and esters saponified with diffi- 
culty (not fat) are not absorbed from the intestines. The 
use of petroleum oil to relieve constipation depends upon 
this fact. 



42 DIGESTION, ABSORPTION AND EXCRETION 

Studies of fat absorption have shown that fat which ap- 
pears in the blood, or which is deposited in the tissues, or 
which is excreted in milk, may retain certain of the charac- 
teristics of the food fat, such as the iodine number, etc. Fats 
are, however, changed in the process of absorption for, fol- 
lowing the ingestion of a food fat with a high melting-point 
the blood fat shows a lowered melting-point while the re- 
verse is true when fat with a low melting-point is ingested. 

The fat content of the blood increases during feeding, for 
the absorbed fat is poured into the blood stream above the 
liver. Studies of the fat content of the blood have shown 
that fat begins to be absorbed about two hours after inges- 
tion and reaches a maximum of absorption in about six 
hours. Bloor has suggested that lecithin takes part in fat 
absorption and that it is the first stage through which 
fat passes in the processes of utilization. In dogs, and by 
analogy probably in man, the fat content of the blood is fairly 
constant, except at times of active absorption from the 
intestines, showing a regulation somewhat similar to that 
observed in the case of glucose. When large quantities of 
fat are being utilized, -as in fasting or diabetes, there is often 
an increase in the blood fat. 

BACTERIAL ACTION AND FECES 

Intestinal Bacteria. — Food is disintegrated through the 
action of bacteria as well as by the digestive processes which 
take place in the intestines as the result of the action of the 
digestive enzymes. Such digestion takes place normally 
and to a greater extent in the large intestine in the case of 
poor digestion and absorption in the small intestine. The 
bacteria active in the intestines may be grouped into two 
general classes: first, those which act primarily upon carbo- 
hydrate material and which produce alcohol and organic 
acids, such as lactic, acetic, butyric, benzoic, succinic, valeri- 
anic acids, accompanied by the evolution of carbon dioxide 
and methane. These are ordinarily classed as fermentative 
bacteria. Their action is not restricted to soluble carbo- 
hydrates; certain kinds are capable of digesting cellulose. 
Bacteria which act upon cellulose are of practical import- 
ance to the herbivora which obtain a portion of their carbo- 
hydrate material through such action. Fermentative bac- 
teria require in general a neutral to slightly acid medium 
for their growth and activities. 

To the second class of bacteria of importance in the diges- 
tive tract belong those whose action is confined primarily 



BA CTERIA L A CTION A ND FECES 43 

to protein material, often classed as putrefactive bacteria, 
and which are chiefly anaerobic. 

The relative number of bacteria excreted per day in the 
feces has been placed at between 33 to 128 x io 12 . A large 
proportion of these are dead. One estimate has placed the 
relative proportion of dead bacteria in feces at 99 per cent. ; 
this value is difficult to determine because of the varying 
conditions in the intestines. The actual weight of dry bac- 
teria excreted per day has been found to be between 5 to 8 
grams. 

Among the products of putrefaction are the proteoses, pep- 
tones, and amino-acids obtained in the usual digestive pro- 
cesses. In addition to these, however, are a number of 
products more or less characteristic of bacterial action, such 
as the nitrogenous substances of the aromatic series — indol 
and skatol, phenol, cresol, phenyl-propionic acid, certain of 
the amines, accompanied often by the development of gas; 
hydrogen, sulphide, carbon dioxide, methane, hydrogen, 
and ammonia. Certain of these products are toxic, partic- 
ularly those of the aromatic series and the amines. 

It has been demonstrated that indol, phenol, skatol, etc., 
are detoxified, conjugated, with sulphuric acid, by the liver 
to form compounds of the type of indican (indoxyl potassium 
sulphate) in which form they are excreted in the urine. Dur- 
ing or after excessive putrefaction these products may not 
be entirely conjugated when various abnormal effects, 
among them nervous disturbances, occur which are ordi- 
narily included in the meaning of the term auto-intoxica- 
tion. The quantity of indican in the urine during a given 
period has been generally accepted as a good index of the 
extent of intestinal putrefaction. 

An alkaline reaction is particularly favorable for the 
growth of putrefactive bacteria. The large intestine is the 
only portion of the intestinal tract in which such a condition 
normally prevails. Some bacteria particularly of the B. 
coli type may be both fermentative and putrefactive in 
effect. They tend, however, to antagonize the putrefactive 
anaerobes. 

In the stomach the action of bacteria ingested with the 
food is retarded if not completely destroyed. The hydro- 
chloric acid of the gastric juice is sufficiently concentrated 
to destroy certain types of bacteria; only the active bacteria 
of other types are destroyed while the spores are resistant 
to its action. Bacterial action, then, in the normal stomach 
is practically negative. It is quite probable that patho- 
genic bacteria, which are ordinarily destroyed by the hydro- 



44 DIGESTION, ABSORPTION AND EXCRETION 

chloric acid of the gastric juice may enter the intestine 
with undigested food particles and oil globules or in water 
that passes through the stomach without becoming acidified 
to any extent. In the presence of large quantities of pro- 
tein, which combines with the hydrochloric acid of the 
gastric juice and tends to lower the acidity of the gastric 
contents or following the ingestion of alkaline drinks or doses 
of alkaline salts, bacteria may develop or escape destruction. 
In certain abnormalities, hyperchlorhydria, atony of the 
stomach, etc., or conditions in which the concentration of 
the hydrochloric acid is lowered through any cause, fermen- 
tative bacteria often develop, and produce organic acids, 
alcohol and carbon dioxide. The excessive ingestion of 
carbohydrate, particularly sucrose (cane sugar) and glu- 
cose, often leads to such fermentation. Yeasts grow even 
in acid solutions. Their development in the stomach is 
accompanied by the production of organic acids, e. g., lactic 
and butyric acids, particularly following the ingestion of 
sugars, in cases in which there is a slow emptying of the 
stomach. 

The reaction of the small intestine is favorable for the 
growth of fermentative bacteria. This is true particularly 
in the lower parts of the small intestine, for the contents 
of the upper portion of the duodenum are slightly alkaline. 
Here the acid contents of the stomach are wholly or partly 
neutralized by the relatively large volumes of pancreatic 
and intestinal juices and the bile, which, while only slightly 
alkaline in reaction, are capable of neutralizing considerable 
acid. In the lower portions of the small intestine, particu- 
larly the jejunum and ileum; the intestinal contents are 
nearly neutral to slightly acid as the result of the partial 
neutralization of the intestinal and pancreatic secretions 
by the hydrochloric acid, and of the organic acids — pro- 
duced during the digestion of fat and probably also by bac- 
terial action. These portions of the intestine are, then, 
favorable to the growth of fermentative bacteria. Exami- 
nation of intestinal contents has demonstrated a pronounced 
growth of such bacteria. The effect of bacterial action in 
this region is not particularly harmful, for the products of 
fermentation are not, in general, toxic. The evolution of 
considerable quantities of carbon dioxide often leads to 
flatulence. Herter has suggested that the presence of an 
excess of fatty acids causes intestinal irritation, and diarrhea. 

Putrefaction and Feces. — Putrefactive processes pre- 
dominate over fermentative in the large intestine. The 
protein material which comes from the small intestine is 



BACTERIAL ACTION AND FECES 45 

here acted upon by the putrefactive bacteria of which, B. 
coli, B. lactis aero genes, Bad. welchi, B. bifidus and certain 
cocci predominate. The character of the bacteria present 
depends to a certain extent upon the nature of the food 
ingested. In a favorable medium certain types of bacteria 
will grow rapidly and in so doing form products which inhi- 
bit the growth of other types. The predominance of B. 
bifidus in the intestinal tract of the infant has been explained 
as due, in part at least, to the continual presence of lactose 
in the diet and to the slight acid reaction of the feces, a con- 
dition which results from the activities of B. bifidus. Acidity 
of the feces is sufficient to inhibit the growth of practically 
all putrefactive bacteria. The gradual change in the diet 
of the infant, even a change from the breast milk with its 
relatively high lactose and low protein content, to cow's 
milk with its lower lactose and higher protein content, tends 
to make B. bifidus disappear and other types, particularly 
B. coli, to predominate. A large proportion of the bacteria 
cultivable on artificial media present in adult feces are B. 
coli. This organism is not entirely dependent upon carbo- 
hydrate ; it can grow either in a carbohydrate-protein medium 
or in one in which available carbohydrate is entirely absent. 

Material which is passed from the small into the large 
intestine throught the ileocecal valve is of practically the 
same consistence as that ejected from the stomach into the 
small intestine; a semiliquid mass. This is true because the 
active absorptive processes of the small intestine, which 
remove both water and solids, are compensated by subse- 
quent excretion of water through the intestinal walls. The 
total mass of the material is, however, greatly reduced. The 
large intestine in man is essentially a concentrating, absorp- 
tive, organ;' its secretion, which is rich in mucus and alka- 
line in reaction, has not been shown to exert material diges- 
tive action. Digestion continues, however, as a result of 
enzymes from the small intestine and other transformations 
result from the action of bacteria. The latter processes 
are of particular importance in certain of the lower animals 
in which the cecum is larger than in other animals. 

In the upper portion of the large intestine the semiliquid 
mass from the small intestine is concentrated; water in 
particular is absorbed. This thickened mass is then passed 
to the transverse and descending portions of the colon, and 
finally out of the body. Observations of the passage of 
food through the large intestine by means of the x-rays 
have lead to the conclusion that, in general, two hours are 
required for transit through each of the three parts of the 



46 DIGESTION, ABSORPTION AND EXCRETION 

colon, i. e., ascending, transverse, and descending. Sleep 
appears to retard, while the ingestion of meals accelerates 
the movement of material in the large intestine. 

The time required for the passage of food through the ali- 
mentary tract varies with the nature of the food ingested 
and with the condition of the individual. According to the 
observations just noted the time is usually from eight to 
twelve hours. Under conditions of regular routine and uni- 
form mixed diet, the residue from food ingested on a given 
day may be eliminated on the following morning. Even 
under such circumstances characteristic particles of food in 
a certain meal may appear in the feces days after the inges- 
tion of that particular food. With the ingestion of a diet 
which is almost completely absorbed, or in fasting, defe- 
cation may take place only once in two or three days. On 
the other hand, foods which irritate the intestinal mucosa 
pass out promptly. 

The material passed from the large intestine varies with 
the nature of the food ingested. It consists chiefly of undi- 
gested and unabsorbed food, bacteria and bacterial products, 
cast-off cells, the residues of intestinal secretions and salts. 
Fecal material is formed even in fasting, such feces consist 
of the residue from intestinal secretions, cellular material, 
bacteria, and bacterial products. 

In the course of digestion relatively large quantities of 
secretions are poured into the alimentary tract and a con- 
siderable quantity of epithelial cells is mechanically removed. 
A large proportion of this material is reabsorbed, a certain 
quantity is, however, eliminated in the feces. 

When considering the absorption of foods from the intes- 
tine, it is necessary to make a distinction between the ma- 
terial remaining undigested and unabsorbed and that secre- 
ted into the intestines in the process of digestion, designated 
as "metabolic products." The quantity of such material 
eliminated has been studied particulary with regard to the 
utilization of nitrogenous foods in which case the "metabolic 
nitrogen" is involved. A determination of the fecal nitro- 
gen excreted in fasting would seem a most logical manner of 
estimating approximately the "metabolic nitrogen" in this 
relation. Studies of the influence of indigestible non-nitro- 
genous materials in their passage through the intestine 
upon the excretion of nitrogen indicate an increase in the 
fecal nitrogen in their presence over that excreted in their 
absence; for a large mass of inert material, in addition to 
holding a certain amount of the secretion by absorption, 
tends to increase the rate of peristalsis. To determine the 



BACTERIAL ACTION AND FECES 47 

"metabolic nitrogen," then, it is essential that a mass of 
non-nitrogenous material 1 be ingested which will yield a 
fecal residue of approximately the same size as that of the 
diet under consideration. Estimates of the metabolic nitro- 
gen of man indicate the amount to be approximately I gram 
of nitrogen per day. Recent experiments in which agar 
agar was used as the inert material have placed this value 
at 0.5 gram of nitrogen per day. 

The degree of indigestibility of the food-stuffs affects the 
quantity of feces formed. Foods which contain a large 
proportion of indigestible material result in a greater fecal 
mass than those which are readily digested and absorbed. 
Foods rich in cellulose yield large watery stools containing 
considerable undigested protein and fat which have been 
protected from the action of the digestive enzymes by the 
indigestible cellulose. The relative composition of the feces 
from easily digestible and completely absorbed food is ap- 
proximately the same irrespective of the nature of the diet. 
This has been demonstrated by feeding diets of meat and 
of rice alternately, in which it was found that the figures for 
percentage composition of the undigested residues were 
quite similar, i. e., the quantity of nitrogen and fat excreted 
in the feces was roughly the same. In these cases the fecal 
material consisted largely of the metabolic products. An 
increase in the quantity of food does not result in an equiv- 
alent increase in the fecal output. An increase of 80 per 
cent, in the quantity of food ingested (bread) has been 
found to cause an increase of only 15 per cent, in the quan- 
tity of feces. With meat the effect is less — because of its 
greater digestibility. Milk has a different effect; an in- 
crease in the quantity of milk ingested results in a propor- 
tional increase in the fecal output, because of the unabsorbed 
inorganic constituents of the milk, calcium, and phosphorus, 
and, to a less extent, of the nitrogenous material. 

We conclude, then, that for easily digestible diets, such 
as meat, eggs, milk, rice, cheese, starches, etc., the fecal 
material consists essentially of the residues from the intes- 
tinal secretions, cellular material, inorganic salts, bacteria, 
and bacterial products. Diets containing relatively indi- 
gestible material, such as vegetables, or those which have 
not been properly digested because of insufficient mastica- 
tion or deficient peristalsis, will yield stools containing food 
residues and probably a greater quantity of non-reabsorbed 
metabolic products than easily and properly digested diets. 

x Agar agar has been suggested for this purpose. 



48 DIGESTION, ABSORPTION AND EXCRETION 

The reaction of the feces is normally neutral to slightly 
alkaline to litmus. Feces from a highly nitrogenous diet 
exhibit an alkaline reaction due to the production of am- 
monia in the process of putrefaction. When fermentation 
predominates, the reaction of the stool will probably be 
slightly acid because of the presence of organic acids pro- 
duced. 

The large intestine is capable of absorbing considerable 
nutriment when it is presented to it as in rectal feeding, par- 
ticularly the products of protein digestion, proteoses, pep- 
tones, amino-acids and the diffusible carbohydrates. This 
is of practical importance in the feeding of the sick, which 
will be discussed later. Cannon has observed the action of 
the large intestine after rectal injection of enemata. He 
studied the effect in cats, of large and small amounts of thin 
fluid masses, and of thick, mushy masses, and found that 
the food was largely in the upper part of the large intestine, 
to which it was carried by antiperistaltic waves. After 
abundant injections the food passed the ileocecal valve and 
into the small intestine. Nitrogen equilibrium has been 
maintained for fifteen days in a boy with a stricture of the 
esophagus when fed per rectum, with a mixture of protein 
(meat) digestion products obtained by digestion in vitro 
with trypsin and erepsin. 



EXCRETION. 

The excretion of the products of general metabolic activity 
takes place through the lungs, kidneys, large intestine and 
skin. Of the products of carbon metabolism, carbon dioxide 
and water, the former is excreted almost entirely through 
the lungs; water is excreted through all excretory channels. 
The nitrogenous end-products of protein metabolism, salts, 
and, to a certain extent, the carbon end-products are ex- 
creted through the kidneys. The feces contain metabolic 
end-products that are excreted through the liver and the 
walls of the intestines, and in addition undigested food 
material and epithelial cells from the intestinal tract, bac- 
teria and their products. The extent to which excretion 
takes place, or may take place through the intestine is not 
well understood. Certain mineral salts, such as calcium, 
magnesium, together with the phosphate radicle, iron, and 
salts of silicon, are excreted into the lumen of the intestine. 
Intestinal excretion of inorganic salts depends to a large 
extent upon the nature of the food ingested, i. e., whether 



EXCRETION 49 

or not it yields an excess of acidic or basic radicles as the 
result of metabolic processes. Because of the appearance 
of the salts of calcium, phosphate and iron in the feces it was 
formerly supposed that these salts taken in the inorganic 
form were absorbed with difficulty, and hence they must 
be supplied in organic combinations. It has been shown, 
however, that they are actively excreted through the bile 
and walls of the intestine. A larger proportion of calcium 
and magnesium appears in the urine following an acid diet 
than occurs from an alkaline diet. Certain substances are 
excreted through the bile : — cholesterol, lecithin, and bile 
pigments. Salts of the heavy metals which are toxic when 
ingested appear largely in the bile, and subsequently in the 
feces. 

Epidermal excretion consists chiefly of water with small 
amounts of nitrogenous waste products, lipins and salts. 

In the course of protein metabolism, the amino-acids, 
and possibly more complex molecules are absorbed from the 
intestinal tract, and are taken up in part by the tissues and 
synthetized into protein molecules. Amino-acids not used 
in the processes of synthesis are deaminized, and the result- 
ant ammonia is converted into urea and excreted; a small 
proportion of the absorbed amino-acids may be stored for a 
time. Such processes take place throughout the body, but 
they occur to a greater extent in the liver and the intestines. 
The carbon-containing fragments of the molecules of amino- 
acids may be oxidized or synthetized into carbohydrate or 
fat. In the tissues protein molecules are broken down 
entirely or in part into amino-acids or simple complexes of 
these which meet a fate similar to those ingested. 

Among the constituents of food and tissues are nitrogenous 
compounds other than simple amino-acids, such, as nucleo- 
proteins and products of their hydrolysis, purin and pyrim- 
idin bases, uric acid, creatine, creatinine, heterocyclic ring 
compounds, urea, and ammonium salts. Some of these are 
not available for body functions and are excreted unchanged ; 
others may take part in cellular activities, although our 
knowledge on this point is not definite. 

Nitrogen is excreted chiefly as urea, ammonia, uric acid, 
creatinine, creatine, and purine. The following table 1 gives 
the composition of urine obtained after the ingestion of two 
types of diet: high and low protein content. 

1 Folin: Am. Jour. Physiol., 1905, xiii, 118. 



50 DIGESTION, ABSORPTION A ND EXCRETION 



Composition of Normal Urine Excreted Following the Ingestion of a 
High Protein and a Low Protein Diet. 



Volume of urine . 
Total nitrogen 
Urea nitrogen 
Ammonia nitrogen 
Uric acid nitrogen 
Creatinine nitrogen 
Undetermined nitro- 
gen . . . . 



High protein diet. 
1170 c.c. 

16.80 gm. 

14.70 " 
0.49 " 
0.18 " 
0.58 " 

0.85 " 



Total SO3 
Inorganic SO3 
Ethereal SO3 
Neutral SO3 



3 64 

327 
0. 19 

0.18 



Per cent. 






Per cent 


of total 






of total 


nitrogen. 


Low protein diet. 


nitrogen 




385 


C.C. 






3.60 


gm. 




87^5 


2.20 


" 


61.7 


3-0 


O.42 


<< 


11 3 


1 . 1 


O.O9 


" 


2.5 


3-6 


0.60 


<( 


17.2 


4-9 


0.27 


" 


7-3 


Per cent. 






Per cent 


of total 






of total 


so 3 . 


O.76 


« 


S0 3 . 


90.0 


O.46 


11 


60.5 


5-2 


0. 10 




13.2 


4.8 


0.20 


11 


26.2 



The greater proportion of the urinary nitrogen is excreted 
as urea. The daily excretion of urea is approximately 30 
grams, equivalent to about 80 to 90 per cent, of the total 
nitrogen in the urine. These values vary with the nature 
of the diet, its protein content, the activity and rate of meta- 
bolism and the degree of retention of nitrogen-containing 
substances. An excessive ingestion of protein or increased 
body activity is accompanied by an increased urea output, 
both absolute and relative; a decreased protein ingestion 
or retention of nitrogen is accompanied by a lowered urea 
excretion. Since urea represents a large proportion of the 
urinary nitrogen determinations of this factor are sometimes 
taken as an indication of the extent and nature of protein 
metabolism. 

The amounts of urea and ammonia which appear in the 
urine are closely related. Urea is formed from ammonium 
carbonates and carbamates. Any factor which prevents the 
transformation of ammonia into urea, such as the formation 
of ammonium salts of highly dissociated acids or the produc- 
tion of excessive quantities of organic acids which are neu- 
tralized by ammonia, induce decreased urea excretion accom- 
panied by increased ammonia excretion. When there is an 
excess of acidic over basic radicles in the body, the acidity is 
reduced by two processes in particular: excretion of the 
acid radicle as a salt of a strong base and of the hydrogen 
in combination with a phosphate radicle, or excretion in 
combination with ammonia. Thus a diet whose ash yields 
an excess of acidic over basic radicles will be accompanied 
by a relatively high ammonia excretion. Or, the presence 
of an excessive quantity of organic acids in the body as the 



EXCRETION 51 

result of a failure to oxidize them is followed by an increased 
excretion of ammonia. 

Creatinine appears in the urine of normal adults in amounts 
comparatively constant from day to day — I or 2 grams — 
but with slight fluctuations throughout the day. Diet has 
little effect upon the excretion of creatinine. According to 
Folin the excretion of creatinine is a measure of endogenous 
metabolism. It has been suggested that there is a relation 
between the mass and activity of the muscular system and 
the quantity of creatinine excreted in the urine. This rela- 
tionship may be expressed in terms of body weight ; it varies 
with different individuals but is fairly constant for each. 
The normal value for the average person has been found to 
be from 7 to 11 milligrams of creatinine per kilogram body 
weight. 

Creatine, which is closely related to creatinine, appears 
in the urine of women at cyclic intervals of menstruation 
and following childbirth and is a normal constituent of the 
urine of children. It also appears during fasting and in 
diseases involving carbohydrate metabolism. There seems 
to be a certain relation between carbohydrate metabolism 
and the excretion of creatine such that in the absence of 
carbohydrates or in disturbed carbohydrate metabolism 
creatine appears in the urine. The ingestion of creatinine is 
followed by an increased creatinine elimination. Creatine, 
when ingested, is accompanied by an increased creatine 
excretion, but has little effect upon the excretion of creati- 
nine. Our knowledge of the importance and significance 
of creatine and creatinine is very limited. 

Uric acid is, in man, an end-product of the metabolism of 
nucleins either of the food or of the tissues, or both. It is 
derived chiefly from the oxidation of purine bases. The 
average excretion for man is about 0.6 gram per day; it 
varies from 0.3 to 1 .2 gram per day. The ingestion of purine- 
containing foods, or accelerated nuclear metabolism, is 
accompanied by an increased uric acid excretion. Uric 
acid is practically insoluble in water; its solubility is de- 
creased in acid solutions and increased in alkaline solutions. 
By varying the nature of the diet, and consequently the re- 
action of the urine, it has been found that the quantity of 
uric acid which the urine is capable of dissolving (or holding 
in solution) is increased by a diet yielding an alkaline ash 
and decreased by one yielding an acid ash. 



52 DIGESTION, ABSORPTION AND EXCRETION 

DIGESTIBILITY OF FOOD 

The food value to the body, of any particular food, de- 
pends upon the quantity of assimilable matter it yields as 
the result of digestion. The relative digestibility of foods is, 
then, an important factor in determining the diet from either 
a clinical or an economic point of view. In feeding the sick 
or delicate persons the ease, rapidity and completeness with 
which the ingested food is^ digested, absorbed and assimilated 
are essential factors. The economist is particularly con- 
cerned with the completeness or extent of digestion, while 
the physician must know something of the ease with which 
food is digested and assimilated. These attributes of meta- 
bolic availability are subject to considerable variation. 
Digestion is influenced by many modifying factors; such as 
psychical influences which accelerate or inhibit the motor 
as well as the secretory activities of the alimentary tract; 
the kind of food; the mode of preparation; the degree of 
comminution, including mastication, and (considering indi- 
vidual food stuffs) the nature of material with which it is 
associated. Psychical stimuli accompanying contentment, 
pleasurable surroundings, well-served and appetizing food 
tend to facilitate digestion, while those which originate from 
fear, anger, worry, keen anticipation, and even high degree 
of happiness inhibit the activities of the alimentary tract 
and thus delay digestion; fortunately the unfavorable emo- 
tions are usually accompanied by a loss of appetite which 
prevents the ingestion of food. 

The quantitative measure of digestibility of a particular 
food-stuff is the ratio between the quantity absorbed and 
that ingested. The degree of absorption is determined by 
subtracting the amount of undigested food-stuff from that 
ingested. In estimating the quantity of undigested material 
in the feces, allowance must be made for the constituents 
which have been secreted or excreted into the intestine dur- 
ing digestion, such as those in the digestive juices, epithelial 
cells, fats, etc., and which, originating in the body, arise 
ultimately from food that has been absorbed. This form 
of excretion, so far as it is related to nitrogenous constituents, 
has been called " metabolic nitrogen." Under abnormal 
conditions, such as excessive or retarded peristalsis the 
digestibility of food varies. With excessive peristalsis, the 
digestive juices do not have sufficient time to act, and there 
is a consequent lower utilization. Such a condition may be 
associated normally with a very bulky diet, such as with a 
predominantly vegetable regimen. 



DIGESTIBILITY OF FOOD 53 

Studies of the comparative digestibility of protein, fat, 
and carbohydrate of various types of foods,when ingested 
by man as a mixed diet, have been made by Atwater. A 
summary of his results is as follows: 

Coefficients of Digestibility of Food-stuffs in Different Groups 
of Food Materials. (Atwater.) 

Protein. Fat. Carbohydrate. 

Protein-rich food: 

Animal food — meat, eggs, dairy prod- 
ucts 97 . 95 98 

Vegetable food — legumes, dried . . 78 90 97 

Carbohydrate-rich foods: 

Cereals 85 90 98 

Sugars and starches . . 98 

Cellulose-rich foods: 

Green vegetables 83 90 95 

Total food: 

Mixed diet 92 95 97 

These values are for ordinary mixed diets. Special meth- 
ods of preparation will modify them to a certain extent, 
e. g., when finely divided vegetable proteins were fed with 
starch and fat the utilization of these substances, in the dog, 
is approximately that of meat, whereas according to Atwater' s 
tables they are much less digestible. Degree of absorption 
does not, however, necessarily determine availibility to the 
body, for a food which is completely absorbed may not be 
of the proper composition for its most economical utilization 
by the body (assimilation). 

When considering foods for the purpose of regulating a 
diet, we are usually concerned with the ease or rapidity 
with which they are digested. A food may be completely 
digested and still be " indigestible" in the sense in which 
this word is used with reference to the facility with which it 
is digested. Our measure of ''facility" is rather indefinite. 
It is ordinarily taken as the time required for a particular 
food to leave the stomach, because until comparatively 
recently we have been unable to study the processes which 
go on in the intestine from a time-relation point of view. 
The rapidity with which food is absorbed from the alimen- 
tary tract may also be accepted as an indication of the ease 
or difficulty with which a food is digested. The rate at 
which nitrogenous or carbonaceous end-products are excre- 
ted has been used as an index of the rate of digestion and 
particularly of absorption. 

The rate of passage of food from the stomach has been 
systematically studied by Cannon, who showed that the 
three important food-stuffs, carbohydrate, protein and fat, 
in equal masses and of approximately the same consistency, 



54 DIGESTION, A BSORP TION A ND EX CRE TION 

when fed alone, leave the stomach at different though char- 
acteristic rates. Carbohydrate-rich foods passed out rather 
rapidly and appeared in the intestines in relatively large 
quantities. Protein did not begin to pass out of the stomach 
for some time. Once it began to appear in the intestines 
it came at a fairly uniform rate for a period of two or three 
hours. Fat also passed slowly from the stomach, more so 
than protein. Mixtures of foods were ejected from the 
stomach at rates which were intermediate between those 
characteristic of the types of foods concerned. The closing 
of the pylorus is dependent largely upon the appearance of 
acid in the duodenum. A food which combines with acid, 
as protein, or which retards the secretion of the gastric 
juice, as fat, passes more slowly from the stomach than carbo- 
hydrate, a food which does not neutralize the acid. The 
order in which foods are ingested also affects the length of 
time required for the stomach to empty itself. A starchy 
food taken after protein food is retarded in its passage out 
of the stomach. Acid foods, those which do not absorb 
(neutralize) much acid, or those which stimulate the secre- 
tion of large quantities of gastric juice, pass out more rapidly 
than foods which absorb considerable acid, are alkaline, or 
inhibit the secretion of gastric juice. Hence the rate of 
movement from the stomach is dependent upon the presence 
of free acid in the gastric juice. Exceptions to this general 
fact occur in disease — such as achylia in which the stomach 
empties rapidly. 

The consistency of the food likewise affects the rapidity 
with which it passes from the stomach: hard particles re- 
tard evacuation of the stomach; protein-food in lumps re- 
mains longer in the stomach than hashed protein, but is 
more completely liquefied than the latter. Dilution of the 
food masses, on the other hand, does not retard their passage 
from the stomach. Practically no difference has been 
observed in the rate with which equal volumes of thick and 
watery mixtures of starchy foods are passed from the stomach ; 
watery protein mixtures pass out more quickly than thick 
mixtures because of the smaller amount of protein present. 

London, using equal masses of solid food, found that the 
quantity of food remaining in the stomach after a definite 
period was the same whether a watery or partially desiccated 
food was fed, but that the degree of digestion was greater 
in the latter case. The water, apparently, tends to pass out 
of the stomach first. Groebbels found, however, that for 
dogs water ingested after bread doubles the time required 
for the food to leave the stomach, and that bread and water 



DIGESTIBILITY OF FOOD 55 

taken simultaneously remained even longer. The absolute 
amount of food taken determines, however, the length of time 
required for the complete evacuation of the stomach. 

Selection of the time required for a particular kind of food 
to disappear from the stomach, as a criterion of the ease or 
rapidity of its digestion is, as we have seen above, of doubtful 
value. To overload the intestine is undoubtedly as harmful 
as to overload the stomach. This is a more difficult matter, 
for the interrelation between the conditions in the intestine 
and the opening and closing of the pylorus are very intimate. 
Our knowledge of the factors affecting the rate of passage of 
foods from the stomach permits us, however, to select diets 
which are suited to the needs of the particular case under 
consideration. Thus a food, highly digestible from the 
quantitative point of view, when fed in fairly large masses, 
would remain for a longer time in the stomach than when 
finely divided as in thick soup, and consequently the protein 
and perhaps the carbohydrate would be more completely 
digested before it passed into the intestines; this increased 
digestion in the stomach should tend to reduce the digestion 
required in the small intestine. The relative digestibility 
of particular foods will be discussed when they are taken up. 



CHAPTER II. 

ENERGY REQUIREMENT 

The energy utilized by man in the performance of work 
and in the maintenance of body temperature is derived from 
the oxidation of the various food-stuffs in the body, particu- 
larly carbohydrates and fats. Extensive studies of animal 
and human metabolism have demonstrated that the law of 
conservation of energy holds for the living organism just as 
it does in the inanimate world. The performance of a defi- 
nite amount of work or the maintenance of a definite temper- 
ature involves the transformation of amounts of potential 
energy into kinetic energy equivalent to the work performed 
or the heat produced. Life is accompanied by the continual 
performance of work in one form or another. A knowledge 
of energy changes in the various conditions and states of 
life is fundamental to a satisfactory understanding and 
control of the diet. 

CALORIC VALUE OF FOOD-STUFFS. 

Oxidation, or combustion, of food-stuffs is accompanied by 
the liberation of energy in the form of heat. When this pro- 
cess takes place under properly controlled conditions, it is 
found that for each unit of material oxidized a definite quan- 
tity of heat is liberated. The measure of heat is the calorie; 
the heat required to raise the temperature of i gram of pure 
water i degree at I5°C. Since this is a relatively small 
unit, for convenience the kilo calorie or Calorie is used, i. e., 
the quantity of heat required to cause the same change of 
temperature in one liter (kilogram) of water. 1 Typical 
food-stuffs measured by this standard yield definite though 
different amounts of energy. 

1 Determinations of the calorific value of foods are conducted with the bomb 
calorimeter. Dried food is placed in a closed metal bomb, lined with a virtually 
unoxidizable metal, such as platinum or gold, charged with oxygen under great 
pressure. The bomb is then immersed in a known weight of water contained in 
receptacle of insulating material to prevent the rapid loss of heat. The food is 
ignited with a small piece of iron wire heated by an electric current. In the 
presence of the large excess of oxygen combustion proceeds rapidly to comple- 
tion and the heat developed increases the temperature of the surrounding water. 
The amount of increase is determined by means of an accurate and sensitive 
thermometer. The caloric value of the food is then calculated from the observed 
change, with proper corrections for radiation, etc. 



CALORIC VALUE OF FOOD-STUFFS 57 

Investigation of the body processes has shown that the 
production of body heat and of work is accomplished at the 
expense of energy obtained by reactions entirely similar to 
those observed in the calorimeter. The quantity of heat 
liberated and the end-products of the complete oxidation of 
carbohydrate or fat are entirely analgous to those obtained 
by experimentation outside the body. But since the end- 
products of complete utilization of protein in the body — urea, 
creatinine, uric acid, etc. — are themselves capable of being 
burned with the liberation of energy, the energy derived by 
the body from protein is less than that obtained in the 
calorimeter. 

In calculating the amount of energy derived from the 
food by the body we must consider that food as eaten is not 
entirely digested nor is the absorption from the intestinal 
tract complete. If allowance is made for that portion of the 
food-stuff which is not assimilated (approximate values: 
carbohydrate 2 per cent., fat 5 per cent., protein 8 per cent.), 
and for variations in degree of utilization, we may assume 
the physiological fuel values as 4.1 Calories per gram for 
carbohydrate, 9.3 Calories per gram for fat, and 4.1 Calories 
per gram for protein. Knowing the relative proportions of 
these primary food-stuffs in any food, we can calculate, with 
the above values, the approximate quantity of heat energy, 
which the body may derive from it. Most of the fuel values 
of foods presented in the various tables in this book are com- 
puted in this manner. 

In the calculation of diets the fuel value of food is usually 
expressed in two forms: (a) the number of calories available 
from a given weight of food, as the pound or gram, and (b) 
the weight of food (grams, ounces, or pounds) which will 
yield a certain number of calories, 100 Calories (kilo-calories) 
or 1000 Calories (kilo-calories). The first method of record- 
ing unit values is most useful in calculating the caloric value 
of a diet which has been consumed as in statistical investi- 
gations of diet, or where the food is taken ad libitum. When 
it is desired to prepare a diet having a given caloric value 
from a diet list composed of dishes of known weight and 
composition, the second procedure is particularly satis- 
factory. 

One Hundred Calorie Portion. — The 100 Calorie portion, 
or the weight of. food which will supply 100 large calories, 
has been suggested by Fisher as a unit for comparisons. 
This unit is useful in comparing not only the relative nutri- 
tive value of various foods but also their cost. The use of 
this unit facilitates the preparation of diets in which foods 



58 ENERGY REQUIREMENT 

of the same types.may be substituted one for another to avoid 
monotony. The proportions of protein, carbohydrate, and 
fat which furnish energy are expressed in terms of percent- 
ages, an arrangement which permits rapid calculations in 
the selection of a properly balanced diet. 

The ioo Calorie portion can be used advantageously in 
the preparation of diets only when slight variations are not 
important, since the results are expressed in terms of por- 
tions or individual pieces; variations will occur in the inter- 
pretation of a portion, composition of food, etc. When the 
portions are weighed out exactly the accuracy is increased, 
but then the usefulness of the method is not realized, for 
it is designed as a ready measure of the caloric value of the 
diet. Books 1 containing data for the composition of various 
prepared dishes and their equivalent caloric yields and pro- 
tein contents, the percentage of calories in the form of fat 
and carbohydrates and of protein are now obtainable. With 
such data a fairly accurate diet may be prepared by serving 
definite proportions of the total recipe after it has been pre- 
pared. 2 

Combustion of food-stuffs in the calorimeter in the presence 
of an excess of oxygen, is initiated by means of a red-hot 
wire and continued rapidly in the presence of heat developed 
as the result of the primary oxidation. Had we been able 
to observe the reaction, we should have noted an intense 
momentary production of heat. Combustion of food in 
the body, on the other hand, involves smaller masses of food, 
molecular in size, and the total quantity of energy liberated 
in one place and at any moment is neither as great nor as 
intense as in the calorimeter. The oxidation proceeds in 
stages: thus a molecule of glucose is oxidized gradually, 
passing through a number of different and successively 
simpler compounds before it is finally converted into carbon 
dioxide and water. Enzymes (oxidases) facilitate these 
processes; the extent and rapidity of which are controlled 
by a close interrelation of numberless enzymic and physical 
factors. The result is the gradual liberation of heat under 
the most favorable conditions for bodily activity. 

Proteins, carbohydrates, and fats all yield energy when 
utilized by the body. 

1 Jurgenson, Kochlehrbuch und praktisches Kochlehre, 1910. Cooper, The 
New Cookery, Battle Creek, Michigan, 19 16. Rose, Feeding the Family, New 
York, 1916. 

2 The use of the data obtained by Gephart and Lusk (Analysis and Cost of 
Ready to Serve Foods, Jour. Am. Med.' Assn., 1915), in conjunction with the 
purchase of food at the particular restaurants concerned will serve to increase 
the knowledge of a patient with regard to the relative food values of various 
prepared dishes, 



RESPIRA TION APPARA TUS 59 

Determination of Energy Requirement. Calorimeter. — 

Heat liberated by an organism in the course of its activities 
can be estimated in two ways: directly by measurement 
with a calorimeter (direct calorimetry) and indirectly, 
through the measurement of the oxygen consumed and the 
carbon dioxide excreted (indirect calorimetry) ; by means 
of a respiration apparatus. A combination of the two 
procedures is often pursued. In the first case the subject 
is placed in a room constructed on the same general prin- 
ciple as a bomb calorimeter; the calorimeter most used in 
this country (Atwater, Rosa, Benedict) is of the adiabatic 
type, i. e. } the temperature of the walls is kept practically 
constant and the heat given off by the subject is absorbed 
by water circulating through metal coils within the chamber. 
The volume of water passed through the pipes and the in- 
crease in temperature are noted and from this data the heat 
evolved is calculated, with suitable corrections. To this 
result must be added the heat carried by vaporized 
water, calculated from the water absorbed from the air 
which has circulated through the chamber. This type of 
apparatus differs from the bomb calorimeter, in which the 
heat evolved is absorbed by water surrounding the chamber. 
Respiration Apparatus. — The respiration apparatus is a 
closed, air-tight chamber in which the subject is placed and 
through which is circulated a current of air. The products 
of oxidation, carbon dioxide and water, are removed from the 
air by absorption, by soda lime and sulphuric acid respec- 
tively, as they pass from the chamber. These determina- 
tions are made either on the total volume of air or from an 
aliquot portion. Knowing the composition of the entering 
air and the amount of carbon dioxide and water produced 
during the experiment, the extent of oxidation can be calcu- 
lated. In the Atwater-Rosa-Benedict apparatus the res- 
piration apparatus and calorimeter apparatus are combined. 
In this case the air passed through the apparatus is circu- 
ated through a closed system. Oxygen is added to the 
air just before it enters the chamber, and carbon dioxide 
and water are removed after it has passed out of the room. 
By this method not only the carbon dioxide and water 
given off can be determined but also the absolute amount of 
oxygen used by the subject can be measured. Comparison 
of the results of direct calorimetry with the calculated values 
from CO 2 excreted and oxygen consumed has shown them 
to be comparable and for short periods — two or three hours 
— the latter method yields results which are perhaps more 
accurate, 



60 ENERGY REQUIREMENT 

A less elaborate type of respiration apparatus is also in 
use, in which the subject breathes through a closed system 
of the same general nature as that described above without 
being confined in a specially constructed room. 

Respiratory Quotient. — The oxidation of different types 
of food-stuffs involves combination with various quantities 
of oxygen and the liberation of variable proportions of car- 
bon dioxide. According to Avogadro's law equal volumes of 
gases under the same conditions of temperature and pres- 
sure contain equal numbers of molecules; hence, when in 
the oxidation of an atom of carbon a molecule of oxygen 
(0 2 ) is used and a molecule of carbon dioxide (C0 2 ) is pro- 
duced, no change occurs in the volume of the reacting gases 
provided the system is returned to the original temperature 
and pressure. Since carbohydrates contain sufficient oxy- 
gen to form water with the hydrogen present in the mole- 
cule, combustion therefore involves only the oxidation of 
the carbon present, consequently the ratio of carbon dioxide 
produced to oxygen consumed ^§f is 1. Fats, on the other 
hand, do not contain sufficient oxygen to combine with their 
hydrogen to form water, and oxygen is utilized for this pur- 
pose in addition to that used in the oxidation of carbon. 
The ratio of ^§f is therefore less than 1 , in this case approxi- 
mately 0.7. Protein is intermediate between fats and carbo- 
hydrates in its state of oxidation. Its ^§f ratio is, there- 
fore, less than one, approximately 0.8. 

From data obtained with the respiration apparatus the 
ratio of carbon dioxide formed to oxygen consumed can be 
calculated; this ratio is designated the respiratory quotient. 
A high respiratory quotient (above 0.8) is taken as evidence 
of the utilization of considerable quantities of carbohy- 
drates, a low quotient (near 0.7) as evidence of the extensive 
utilization of fat by the body. When carbohydrate is trans- 
formed into fat, oxygen is derived from the carbohydrate 
and the respiratory quotient may be greater than 1, whereas 
in the case of diabetes, protein is converted into carbohy- 
drate and excreted in the urine, less oxygen is excreted as 
C0 2 than would normally be the case, and the respiratory 
quotient may be less than 0.7. Results obtained through 
the calculation of such quotients have been of great value 
in indicating the differential utilization of food-stuffs in the 
body. 

Basal Metabolism. — Two methods of attack have been 
employed in determining the total quantity of energy re- 
quired and the relative proportions of the food-stuffs most 
suitable for individuals under varying conditions. One, 



BASAL METABOLISM 61 

the statistical method, consists in estimating, from observ- 
ations of a large number of individuals the average quantity 
and composition of the food eaten by normal individuals 
during comparatively long periods of time. Such experi- 
ments have been carried out in many countries and upon 
groups of individuals employed in different occupations. 
These data form a very substantial basis for our deductions 
regarding the food requirements of man. 

The second and more exact method is to determine by 
means of a calorimeter, or respiration apparatus, the energy 
exchange of the body under different conditions of activity 
and states of nutrition. A combined study of the energy 
exchanged and of the excreta, including the carbon dioxide 
and water expelled by the lungs (universal respiration ap- 
paratus) enables us to estimate the relative amounts of the 
various food-stuffs utilized by the body. Studies of this 
sort yield very definite results. The accuracy of these ex- 
periments tends to counter-balance the deficiencies arising 
from the smallness of the number, and the shortness of the 
periods of observation in this mode of investigation. At- 
water, and later his collaborator, Benedict, have collected 
a large amount of data by both methods of investigation 
upon the dietetic habits of the American people. It is 
largely upon their results that our ideas of food require- 
ments are based. 1 

For the estimation of the energy requirements of different 
individuals and as a basis of comparison between them in 
experimental work it is essential to have some standard by 
which they may be measured. 

Such a standard in metabolism or basal energy require- 
ment is taken as equivalent to the heat liberated by a fasting 
man (post-absorptive condition twelve to fifteen hours after 
the last meal) when lying down, asleep and comparatively re- 
laxed. It may be expressed in terms of the total daily 
energy requirement, or in smaller units, such as the energy 
liberated per-kilogram of body weight or square meter of 
body surface in an hour. Values based on the unit of body 
weight are suitable only when comparing individuals of 
approximately the same size, shape and weight; since, in 
general, a greater amount of energy is produced per unit of 
weight by a small than a large organism. For the compari- 
son of different individuals, as a man and a child, or of two 
men of different sizes, expressions of the energy metabolism, 

1 Benedict, Lusk, DuBois, Howland and Murlin have recently contributed a 
large amount of work bearing upon the fundamental basis of energy exchange, 
basal metabolism, in the normal adult and child in disease. 



62 



ENERGY REQUIREMENT 



44 


66 


88 


WEIGHT- 
110 132 


-POUNDS 
154 


176 


198 


220 


242 


79 
75 
71 
67 
63 
59 
55 
51 
47 


190 
180 

CO 

£170 

|l60 
h 

wl50 
o 

h-140 

X 

o 

S130 

X 

120 
110 

100 

1 








1.5 


1.6 


1,7 










S2.0 




S2.1 




2.2 




,2.3 ^ 


1.2 


1.3 


1.4 
\ 


\ 


'v 








\1.8 


\L9 


















1.1 \ 


\ 1 






\ 


\ 




























\ 






























Nl 


a.o^ 




\ 






















\ 


u 






\ 


\ 




\ 


[^ 


\ 












"^1.7 


^i: 


i 


















^ 


v 










""1.6 






























\ 


1.1 


















V 


V 9 












1.3 






















\ 








vi.o 


1.1 


























?Ci 





3 





i 


J 


5 





G 





70 


80 


90 


100 


110 



WEIGHT- KILOGRAMS 



Fig. i. — Chart 1 for determining the surface area of man in square meters from 
weight in kilograms (Wt.) and height in centimeters (Ht.) or their equivalents 
in pounds and inches, according to the formula: 

Area (sq. cm.) = Wt. ' 425 X Ht. °- 725 X 71-84- 



Standards of Normal Metabolism. Average Calories per Hour peb 
Square Meter of Body Surface. 2 



Subject, 
age in years. 

Boys, twelve to thirteen 
Men, twenty to fifty . 
Women, twenty to fifty 
Men, fifty to sixty . 
Women, fifty to sixty . 



According According to linear and 
to Meeh's height-weight 

formula. formulas. 



7 


49-9 


7 


39-7 


3 


36.9 


8 


35-2 


7 


32.7 




Fig. 2.— Variation of basal metabolism with age: Calories per square meter 
of body surface per hour. Only the results of male subjects were used in making 
this curve; the metabolism of female subjects is slightly lower. (Russel Sage 
Institute of Pathology.) 

DuBois and DuBois; Arch, Intern. Med., 1916, xxvii, p. 863. 
2 Gephart and DuBois: Arch, Int. Med., xvii, 913. 



BASAL METABOLISM 



63 



Percentage Increase or Decrease in the Hourly Basal Metabolism for 

Various Factors Affecting the Extent of Energy Metabolism. 

(Adapted from the Work of Lusk and DuBois.) 



Average man, 154 pounds (70 kg.), 

at complete rest, 70 Calories per 

hour: 
Ingestion of food . 
Lying in a chair, supported 
Sitting up in chair . 
Moderate activity in chair 
Very restless in bed 
Exercise : 

Walking on level, 2.J miles per 
hour 

Climbing, 2.7 miles per hour 

Hard labor, bicycle riding . 

Thin but healthy 

Fat but healthy 

Disease : 

Most patients not seriously ill . 

Obesity 

Diabetes with severe acidosis . 

Severe pernicious anemia . 

Acromegaly 

Cancer, severe heart and kidney 
disease and high fever 

Leukemia 

Typhoid fever 

Convalescence 

Exophthalmic goiter: 

Mild 

Severe 



iase or decrease, 


Additional Calories per 


per cent. 


hour for average man. 




Increase. 




5 to 10 




4 to 7 


O 







8 




6 


29 




20 


20 to 100 




14 to 70 


230 




160 


580 




407 


756 




529 


















+ 10 to — 10 




+ 7 to —7 


+ 10 to — 10 




+ 7 to— 7 


oto 15 




to 10 


to 20 




to 14 


to 30 




O tO 21 


20 tO 40 




14 to 28 


30 to 60 




21 tO 42 


40 to 50 




28 to 35 


10 tO 20 




7 to 14 


25 to 50 




18 to 35 


75 to 100 


Decrease. 


53 to 70 


— 10 to — 30 




7 tO 21 


—10 to —35 




—7 to —25 


—25 to —50 




—18 to —35 



Prolonged undernutrition . 
Diabetes, emaciated 
Cretinism and myxedema . 

Example: Man, aged fifty to sixty years; height, 67 inches (170 cm.); weight, 
154 pounds (70 kg.);office work most of day (fourteen hours); walks two hours; 
bed, eight hours. 

Calories per hour. 

(a) Area, from chart, 1.8 square meters. 

(b) Basal metabolism per square meter of body surface 

(Table, p. 62, man 50-60) 

(c) Basal metabolism of 1.8 X 35.2 

(d) Increase for food, 10 per cent, (used in all calcula- 

tions), 63 X 0.1 . 

(e) Increase for bed, resting basal metabolism plus food 

(c + d),or6 3 + 6 

(/) Increase for office work, moderate activity in chair, 

29 percent.; 63 X 0.29 18 

(g) Increase for walking (on level), 230 per cent.; 

63 X 2.3 145 

Then for the day: Calories per day. 

Bed: Eight hours = (c + d) X 8 or (63 + 6) X 8 . 552 
Office work: Fourteen hours = (c + d + f) X 14 or 

(63 + 6 + 18) X 14 1218 

W T alking: Two hours = (c + d + g) X 2 or (63 + 6 + 

145) X 2 428 

Total for day 2198 



35-2 

63.4 (drop 0.4) 



69 



64 EN ERG Y REQ UIREMENT 

in terms of unit surface, are more accurate and comparable; 
the number of Calories per square meter per hour is usually 
selected as the unit of reference. Benedict has recently 
proposed that basal metabolism be expressed in calories 
per day or hour determined from equations which involve 
weight, height and age as factors. 

The relative value of body weight and body surface as the 
basis of comparison between different individuals has re- 
cently been studied by Benedict and by DuBois and their 
co-workers. DuBois has studied the relation of body sur- 
face and basal metabolism, and as a result, advocates the 
use of body surface as the basis of comparison between 
different individuals. His conclusions are based upon data 
obtained from the measurements of the energy exchange 
and of body surface ; the latter was determined by a new and 
more accurate method than any hitherto described. With 
the aid of this data DuBois has shown that Meeh's formula 1 
for calculation of body surface which has been in general 
use, does not give accurate results for any but a selected 
(average) group of individuals. DuBois and DuBois 2 have 
derived a formula (linear formula) in which only linear 
measurements are concerned; determinations of length and 
circumference. This formula necessitates a number of 
careful observations and calculations. For any but the 
most exact work the following simple formula may be used. 
It involves but two factors, height and weight (height- 
weight formula): A = W°* 425 xH * 725 x 71.84, where A is the area 
in square centimeters; H, height in centimeters, and W, 
weight in kilograms. With this formula, or more conveni- 
ently with the chart on page 62, the extent of body surface 
can be readily calculated. 

The errors in the linear formula and the height-weight 
formula have been estimated at a maximum of ±5 per 
cent., average =t 1.5 per cent, while Meeh's formula gives a 
variation of =1=30 per cent., average 15 per cent. The maxi- 
mum deviations obtained with DuBois' formula apply 
particularly to those of unusual shape. 

While the basal metabolism of various individuals is 
nearly the same per square meter of body surface, such a 
comparison is not exact in all cases. Benedict and more 
recently Harris and Benedict have considered the factors 
which modify basal or standard metabolism. From an 
analysis of data obtained in a series of investigations conduc- 

^eeh's formula: S=Cn/W 2 where S is surface; W, weight and C a constant 
dependent upon the shape of the solid; for man C is 12.3. 
2 Arch, Int. Med., 1916, xvii, 855. 



Basal metabolism 65 

ted under similar conditions, in the post-absorptive condi- 
tion, Benedict called attention to various factors which 
modify the basal metabolism of different individuals, such 
as height, weight, activity, age and sex. Harris and Bene- 
dict 1 have made a statistical study of the determinations 
of the basal metabolism of 136 men, 103 women, and 93 in- 
fants. A correlation was found between body weight and 
heat production and between stature and heat production 
which was higher in the first case than in the second. These 
factors, weight and height, appear to have independent 
significance for the prediction of basal metabolism. The 
degree of correlation is higher for men than for women, but 
apparently not greater for male infants than for female 
infants. With increasing age throughout adult life, there 
is a decrease in heat production which is less for women 
than for men. This decrease in total daily heat production 
is essentially uniform from year to year; the daily meta- 
bolism is reduced 7.15 Calories for men and 2.29 Calories 
for women each year. Women are, in general, smaller than 
men, if then, the metabolism of the two sexes to be compared 
on the basis of unit of body weight or unit of body surface 
it is found that there is a much smaller difference than that 
given above. The difference between men and women is 
less when compared on the basis of body weight than of 
body surface. In any case the metabolism of women is 
found to be less than that of men. When the effect of 
body weight, stature and age are taken into consideration 
women show a metabolism approximately 6.4 per cent, less 
than that of men. 

The value of the unit of body weight and of body surface 
in predicting the basal metabolism of different individuals 
has been questioned by Harris and Benedict. These 
authors show that the "body surface law," which assumes 
that the heat production of an organism is proportional to 
its superficial area, is open to question. Such a law pre- 
supposes the constancy of heat production in the same 
individual at different times and also a constancy of heat 
production per square meter of body surface in different 
individuals. These conditions are not fulfilled in the case 
of fasting men or men subjected to under-feeding in which 
the changes in metabolism are not commensurate with the 
changes in body surface. The influence of sex, age, and 
activity are also deviations from the body surface law. 

1 Harris and Benedict: Carnegie Publications, 19 19, 279; Proc. Natl. Acad 
Sciences, 1918, 370. 



66 ENERGY REQUIREMENT 

Heat production was found to be highly and apparently 
equally correlated with body weight and body surface. 
Predictions of basal metabolism on the basis of body surface, 
using DuBois height weight chart, have apparently a slight 
superiority over the use of body surface when these two 
methods are compared upon a statistical basis. The appar- 
ent greater accuracy of body surface as a unit of comparison 
is held to be due to the fact that body surface takes into ac- 
count both weight and height. 

An equation for calculation of a standard of basal 
metabolism for adults in the range covered by Harris and 
Benedict has been developed. This equation takes into 
consideration the factors found to be most evidently related 
to the quantity of heat produced in human adults; height, 
weight and age. These equations for the total daily basal 
metabolism are: 

For men, & = 66.4730+ 13.7516 w+5.0033 5-6.7550 a. For 
women, ^=655.0955+9.5634 w+1.8496 5-4.6756(2. Where 
h= total heat production per 24 hours, w= weight in kilo- 
grams, s= stature in centimeters and a=age in years. 1 
These equations predict the total daily basal metabolism of 
various individuals more accurately than the DuBois formula. 
Calculations of the total daily metabolism must take into 
account the daily activities of the individual under con- 
sideration. The hourly basal metabolism calculated from 
these equations can be used with the percentage variations 
in activity indicated on page 63 if desired. 

Basal metabolism varies with activity, age, size, sex, 
training and disease. In considering the average energy 
requirement the effect of these factors must be recognized 
even though we do not have at present all the necessary 
data to correct them in our estimations. Sufficient data 
have been collected with regard to age to indicate the trend 
of the variation and to permit the use of such data in calcu- 
lating energy requirements during certain periods of life. 
Benedict holds that "the basal metabolism is a function of 
both the total mass of active protoplasmic tissue and of 
the stimulus to cellular activity existing at the time^ the 
measurement of metabolism is made." Body composition 
i. e., proportion of active protoplasmic tissue to the inert 
body fat, has an effect upon the basal metabolism, thus the 

tables have been prepared by Benedict and Harris in their publication to 
facilitate calculation, which involve only the addition of two figures. These 
tables are too extensive for publication here. If the above equations be abbre- 
viated such that all figures below unity except the first be eliminated these equa- 
tions will be found to be easily handled and accurate for practical purposes. 



BASAL METABOLISM 67 

tendency of athletes toward a higher metabolism when com- 
pared with non-athletes is to be ascribed to their greater 
muscular development; the lower metabolism of women 
than of men, is apparently associated with their greater 
proportion of inert body fat (lower muscular development) 
and in part to an inherent characteristic of sex; tall persons 
have a greater metabolism than short individuals since they 
have proportionately greater amounts of muscular tissue. 
Another factor that modifies the basal metabolism, stimula- 
tion of cellular activity is influenced by a number of factors: 
age, sleep, character of preceding diet and after-effects of 
severe muscular work; there are also variations in the diur- 
nal as well as day-to-day metabolism. 

The effect of age has been more extensively studied than 
the other factors which affect the basal mtabolism. The 
active youth has a higher rate of metabolism than a person 
in middle life, while an old man has a still lower metabolism. 
The metabolism of an infant is low during the first month, 
after which it becomes much higher. In childhood the basal 
metabolism is above that of the adult, with increasing age 
the rate of metabolism decreases until it reaches that of the 
adult at about twenty years of age ; there is a slight rise at 
about puberty. During adult life the rate of decrease of basal 
metabolism is fairly uniform and rather gradual ; it is greater 
for men than for women. The chart on page 62 indicates 
the variations in basal metabolism with age. In calculating 
the metabolism of persons of different ages, no correction 
need be made when the Harris-Benedict formula is used 
(for adults); with the DuBois chart page 62 the standards 
of normal metabolism proposed by Gephart and DuBois 
may be used. 

Daily habits and the nutritional condition affect the 
energy changes. A fasting subject lying perfectly still 
immediately after waking in the morning has been shown 
to have an average metabolism which was 13 per cent, 
higher than when asleep. Later in the day under similar 
conditions the metabolism increased to 22 per cent, above 
the resting state. Prolonged fasting results in a lower 
metabolism than before fasting. Severe muscular work 
is accompanied by a continued higher rate of metabolism 
some time after the cessation of work. These variations 
have been ascribed by Benedict, as indicated above, to an 
alteration in the stimulus to cellular activity. The effect 
of a decrease in body weight in the same individual is a 
lowered rate of metabolism. A 12 per cent, loss of weight 
was found to be accompanied by an energy requirement 



68 ENERGY REQUIREMENT 

which was approximately one-third less, and the heat out- 
put per kilogram of body weight or per square meter of body 
surface was 18 per cent, less than that required at the origi- 
nal weight (Benedict). 

In addition to the factors which modify the basal meta- 
bolism there are others which have a direct effect upon the 
total daily metabolism: food, activity, temperature and 
disease. The ingestion of food causes an increase in the 
rate of metabolism. Experiments upon fasting men and 
animals have established the fact that after the removal of 
the effect of the previous diet, which affects metabolism 
during the first part of a fast, the energy production is low 
and practically constant. If to such an organism food be 
given, there will be an increase in the basal energy meta- 
bolism which will vary with the kind and quantity of food 
ingested. Protein exerts a greater stimulation than carbo- 
hydrate or fat. Small quantities of food will increase the 
basal energy metabolism from 5 to 10 per cent. While 
following the ingestion of large quantities of food, the in- 
crease may be as high as 40 per cent. This increase begins 
in the case of proteins and carbohydrates, in from a half- 
hour to an hour after the ingestion of food, while following 
the ingestion of fat there is little increase until five or six hours 
afterward. The increase in the basal metabolism following 
the ingestion of food is designated as the specific dynamic 
effect of food. The effect of protein has been shown by Lusk 
to be due to a stimulation of the metabolism of the cells by 
certain of the amino-acids. The effect of carbohydrate and 
fat, on the other hand, is due to the mass action of these 
food-stuffs in the circulation — as the result of plethora. 
Benedict has also suggested that this increased metabolism 
is the result of stimulation of cellular activity. 

Muscular activity has a direct effect upon the energy 
requirement of an individual. In studying the basal energy 
metabolism of a fasting man, as indicated above, it was 
found that the metabolism was increased 13 per cent, above 
that of the sleeping metabolism merely as the result of being 
awake, and that continued mental activity and prolonged 
muscular activity resulted in a further increase of 9 per cent, 
in the basal metabolism measured under conditions of com- 
plete repose later in the day. As the intensity increases 
there is a proportionate increase in the energy exchange. 
Energy-yielding food must be supplied to meet this increase. 

Training in the performance of work has a tendency to 
reduce the energy requirement for a given piece of work. 
The beginner makes a greater effort to perform his work, for 



BASAL METABOLISM 69 

many false motions are made; the result is an increased 
metabolism. Experience and routine gradually reduce the 
number of unnecessary movements with a corresponding 
reduction in the energy exchange. 

Studies of the relative efficiency of the human body — the 
proportion of energy contained in food which is transformed 
into work — shows the body to be a very efficient machine. 
Experiments in which a man rode a specially constructed 
bicycle, by means of which the work performed in riding 
could be measured, showed that 35 per cent, of the total 
energy transformed during muscular work was used in the 
accomplishment of the work. In general, however, the 
efficiency of the body in converting the potential energy in 
the food into work is found to be approximately 20 per cent. 

The energy required to accomplish a given 1 amount of 
work was found to be the same irrespective of whether the 
body was in the best of nutritive condition or had lost weight 
as the result of fasting. The effect of loss of weight is to 
result in an economy ih the basal metabolsim and a lower 
energy requirement for the performance of work because 
of the smaller weight, but for similar amounts of work the 
energy expended was the same. Work performed following 
the ingestion of carbohydrate, glucose, did not result in an 
increased energy output above that for the same amount of 
work without carbohydrates, i. e., -there was not a summa- 
tion of the energy required for work and extra heat produced 
following the ingestion of carbohydrate. Meat and alanine, 
however, exerted their specific dynamic effect upon the meta- 
bolism with the production of energy which was not utilizable 
for the production of work. In this case the energy produc- 
tion for a given amount of work was equal to that required 
for the work performed without food plus the extra heat 
resulting from the effect of the protein or its products. 

To meet the increased energy requirement which accom- 
panies muscular activity the body must be supplied with 
greater quantities of energy-yielding food. Protein metab- 
olism, as we will show later, is not increased to any extent 
during work provided sufficient fat and carbohydrate are 
present. Fat is capable of yielding a greater quantity of 
heat per gram than carbohydrate. Carbohydrate, on the 
other hand, is apparently more readily oxidized in the body. 
Studies of the respiratory quotient during work has demon- 
strated an increased utilization of carbohydrate at such 
times. These observations indicate that the stores of carbo- 

1 Anderson and Lusk: Jour. Biol. Chem. 1917, xxxii, 421. 



70 ENERGY REQUIREMENT 

hydrate are being utilized for the performance of work in 
preference to the fats. The use of carbohydrate as a prime 
source of energy is emphasized by the fact that following 
the cessation of work the body appears to be subsisting in the 
presence of a depleted store of carbohydrates (Benedict). 
Other experiments show, however, that fat is capable of sup- 
plying the energy requirement of the body, particularly in 
the presence of small quantities of carbohydrate. In a sud- 
den burst of activity, then, carbohydrates are more satisfac- 
tory than fats. In long-continued activity the fats which 
are apparently oxidized with difficulty are extensively utilized. 
Where there is an excessive prolonged energy requirement 
such as in continuous severe labor and in cold climates, an 
increase in the more concentrated fats in the diet is desirable ; 
for, were the heat derived entirely from carbohydrates it 
would entail an excessive ingestion of vegetable food. 

Age, with its variation in the processes of metabolism — in 
the young the predominance of anabolic over catabolic func- 
tions (formation of new tissues) continuous activity and 
greater rate of metabolism as contrasted with the slower 
movements, lowered rate of metabolism and muscular tone 
accompanied usually by decreasing weight with age — exhibits 
a variation from the requirements of the average adult in 
the prime of life. 

Disease affects the basal metabolism; it may be increased 
as in exophthalmic goiter (Grave's disease) 75 to 100 per 
cent. ; in typhoid fever, 40 to 50 per cent. ; in anemia, cancer, 
severe cases of heart and kidney disease and high fevers, 20 
to 40 per cent.; it may be decreased as in cretinism and 
myxedema 20 to 50 percent. ; or it may approximate the normal 
rate as in diabetes. Considerations of the energy require- 
ment in various diseases will be found in discussions relating 
to them. It is an interesting fact that in typhoid fever 
when the basal metabolism is markedly increased, the inges- 
tion of food is not accompanied by a marked increased heat 
production or specific dynamic effect. This fact is of im- 
potance,for it permits, on a scientific basis, the feeding of 
fever patients with the large quantities of food necessary 
to meet the requirements of their increased metabolism 
without fear of materially augmenting the metabolism 
because of the inherent stimulating effect of the food itself. 

To summarize our discussion: The energy metabolism 
of various individuals of different sizes may be quite accur- 
ately compared on the basis of the extent of their body sur- 
face The intensity of metabolism varies with the mass of 
active protoplasmic tissue and the stimulation to cellular 



BASAL METABOLISM 71 

activity as represented, for example, by sex and age. Food- 
stuffs have their specific effects upon the rate of heat produc- 
tion. The varied activities of life aside from those included 
in the basal metabolism are associated with an extra expendi- 
ture of energy. Evaluations of the daily average metabolism 
include allowances for all such variations in activity and 
they must be used accordingly. 

When it is desired to know the energy requirements of an 
individual with a fair degree of accuracy the value should be 
calculated with the use of the height weight formula of 
DuBois or the equation of Benedict, see p. 62 to 66, making 
suitable corrections for activity and disease if present. 
When a rough approximation is all that is desired the data 
in the tables given below are sufficient. 

Calories 
per hour. 

Man sleeping 65 

Man sitting at rest 100 

Man at light muscular exercise 170 

Man at active muscular exercise 290 

Man at severe muscular exercise 450 

Man at very severe muscular exercise 600 

In estimating the daily energy requirement of a man the 
day is considered as being made up of a number of periods of 
various types of activity whose hourly energy transformations 
are approximately known. The total requirement is, then, 
a summation of these hourly transformations. Such calcu- 
lation of the heat exchange has been made for an average 
man at light muscular work, taking into consideration the 
variation in activity. 

Calories Heat 

per hour. output. 

At rest, sleeping eight hours 65 520 

At rest, awake, sitting up six hours . . . . 100 600 

Light muscular exercise ten hours . . . . 170 1700 

Total output of heat for twenty-four hours 2820 

The daily energy requirement of man under various condi- 
tions has been given by Lusk as follows : 

Calories 
per day. 

In bed twenty-four hours; absolute rest without food . . 1,680 

In bed twenty-four hours; absolute rest with food . . . 1,840 
In bed eight hours; work in which sitting in a chair, sixteen 

hours; with food 2,170 

In bed eight hours; in a chair fourteen hours, moderate exer- 
cise, two hours 2,500 

In bed eight hours; in a chair fourteen hours, vigorous exercise 

two hours; with food 3, 000 

Farmer, active exercise 3.500 

Lumberman 5,000 

Rider in a six-day bicycle race . 10,000 

The following table gives the extra calories attributable 
to occupation and the total daily metabolism for average 
men and women at various occupations : 



72 



ENERGY REQUIREMENT 



Extra Calories per Hour Attributable to Occupation and Total 
Daily Metabolism for Various Occupations. (Lusk.) 1 

Total daily 

Extra metabolism. 

Occupations of men. calories Average man 

per hour 5 ft. 8 inches 
and 155 lbs. 

Basal 1770 

Hospital ward 1900 

Tailor 44 2240 

Bookbinder 81 2530 

Shoemaker 90 2600 

Metal worker, filing and hammering . . 141 3000 

Painter of- furniture 145 3050 

Carpenter making table 164 3200 

Stonemason chiseling tombstone . . . 300 4300 

Man sawing wood 378 4900 

Average woman 
Occupations of women. 5 ft. 4K inches 

and 134 lbs. 

Basal 1480 

Hospital ward . 1580 

Seamstress, needlework 6 1630 

Typist, 50 words per minute .... 24 177° 

Bookbinder 57 2030 

Seamstress using sewing machine ... 63 2080 

Housemaid, moderate work 81 2220 

Laundress, moderate work 124 2560 

Housemaid, hard work ...... 157 2830 

Laundress, hard work 214 3490 

The following daily energy requirements for infants and 
children have been suggested. 

Energy Requirements for Children. 

Total Calories 
per day. 

1 tO 2 900 tO 1200 

2 to 5 ... 1200 to 1500 

6 to 9 . . . ... . 1400 to 2000 

10 tO 13 1800 tO 2200 

14 to 17 girls 2200 to 2600 

boys 2500 to 3000 2 

Atwater has given comparative values for the metabolism 
of the different members of a family. On the basis of the 
father having a rate of I , the energy requirements of the rest 
of the family would be: 

Father 1.0 

Mother 0.8 

Sons: 14 to 17 0.8 to 1.5 

Daughters: 14 to 17 o.7toi.o 

Children: 10 to 13 o.6toi.o 

6 to 9 0.5 

2 to 5 0.4 

Under 2 0.3 

^our. Am. Med. Assoc., 1918 lxx 821. 

2 Lusk and Gephart have found from a study of the food eaten by boys in 
a fashionable boarding school that an active boy may consume food equivalent 
to 4000 to 5000 calories per day. 



CHAPTER III 
PROTEIN REQUIREMENT. 

In our previous discussions, as well as in our subsequent 
discussions relating to protein-rich foods, we have taken up 
the composition of protein material in general, its digestion, 
absorption, and the change which it undergoes in the process 
of assimilation. At present we are concerened with the quan- 
titative relation of protein in the diet and the factors which 
influence this. 

Protein as we have already found, is an essential constit- 
uent of our daily dietary. Energy may be derived from por- 
tein, fat or carbohydrate but only protein or its products of 
hydrolysis can furnish the amino-acids necessary to replace 
the loss of nitrogenous material in the tissues resulting from 
the general bodily functions or for the constructive processes 
of growth. 

The necessity for the presence of protein in the dietary 
was early recognized. It was, in fact, a more difficult task 
to demonstrate that this food constituent was concerned 
more particularly in the structural changes of the body than 
primarily as a source of energy for muscular work. We no 
longer say, as did Liebig, that protein is the source of muscu- 
lar energy, but recognize that this function belongs to the 
carbohydrates and fats, and consider protein as the chief 
source of material for the repair of the wear and tear in the 
muscles and other parts of the body. 

Admitting that the necessity for protein is so well estab- 
lished that it is practically self-evident, we may take up the 
question of the quantity of protein necessary for the body, 
how it may be supplied, and the relative efficiency of protein 
for the needs of the body. 

Methods employed for the study of these problems are in 
general the two considered in our discussion of the energy 
requirements of the body: the purely experimental and the 
statistical. In the experimental studies use is made of the 
nitrogen balance or of the rate of growth of young animals, 
such as rats, when compared with the normal rate of growth. 
For the determination of the nitrogen balance the nitrogen 
content of the food — representing the protein material — 



74 PROTEIN REQ U I RE ME NT 

feces, urine, and in some cases the hair, scurf and excretions 
from the skin, are analyzed for definite periods of time. The 
quantity of nitrogen found in all of the excretions is then sub- 
tracted from that in the food. If the result is a positive fig- 
ure, that is, if there is less nitrogen in the excretions than in 
the food, then the subject is said to have a positive nitrogen 
balance, for he has retained in his body a certain amount of 
nitrogen-containing material. If the result be a negative 
value, i. e., more nitrogen in the excretions than was con- 
tained in the food, the subject has supplied nitrogenous 
material from his tissues and is said to have a negative nitro- 
gen balance. A normal adult is usually in an approximate 
nitrogen equilibrium. During growth and regeneration — 
youth, pregnancy and convalescence — the organism normally 
shows a positive balance. In conditions of emaciation, 
fever or wasting diseases a negative balance is obtained. 

The average daily protein metabolism or plane of nitrogen 
equilibrium varies in the same individual, according to the 
quantity of protein ingested. A sudden change from a low 
to a high protein diet, or vice versa, is not accompanied by an 
equally abrupt variation in the daily excretion of nitrogen. 
Instead there is a gradual increase or decrease in the quantity 
of nitrogen eliminated until the new plane of metabolism is 
finally attained and the subject is once more in nitrogen 
equilibrium, approximately three days. When protein food 
is completely removed from the diet the total nitrogenous 
excretion is an index of the internal, or endogenous, meta- 
bolism of the individual. 

An exact determination of the endogenous protein metab- 
olism of man is the ideal basis for the study of the needs of 
the body. This is a difficult procedure, for many contribut- 
ing factors modify the quantity of nitrogen excreted— our 
measure of the rate of the protein metabolism. When all 
of the food elements are removed as in fasting, we might 
expect to obtain a measure of the endogenous protein, 
metabolism. Experiments upon men and animals have 
shown, however, that this is not the case, for a number of 
modifying factors, such as the previous diet and the quantity 
of fat and carbohydrate (glycogen) present in the body, will 
modify the course of the cellular activities and the protein 
metabolism. 

The plane of protein metabolism in the early stages of 
fasting is affected by the previous dietary regimen. When 
this diet has been rich in protein, a larger quantity of nitro- 
gen is excreted in the urine than would have been obtained 
had the diet been poor in protein — just as with a normal 



PROTEIN REQ U I REM EN T 75 

diet, if the protein quota be decreased, the nitrogenous ex- 
cretion changes gradually and not abruptly from one level 
to another. It is evident, therefore, that it would not be 
accurate to accept the quantity of nitrogen excreted in the 
early part of a fast as a measure of the endogenous protein 
metabolism. Neither can we accept the nitrogen excreted 
after the effects of the previous nitrogenous diet have passed, 
for during this period of readjustment other factors have 
been developing an abnormal influence. The normal man 
is accustomed to derive the greater portion of his energy 
from the oxidation of carbohydrates and fats. A fast is 
commenced with a small reserve of carbohydrate, glycogen, 
and a somewhat larger reserve of fat. During the first few 
days, while the effects of the previous diet have been dis- 
appearing, practically all of the glycogen reserve has been 
utilized and after this the body subsists upon a diet, so to 
speak, of fat and protein. The removal of carbohydrate 
material from the diet of a man who is accustomed to this 
food element in his diet results in a disturbance of his meta- 
bolism, particularly a change in the fat metabolism. Under 
such conditions the body seems to be unable completely to 
oxidize fats. Partially oxidized fatty acids are passed into 
the blood stream and these cause a disturbance of the equili- 
brium between the acidic and basic radicles which has its 
effect upon the respiratory and salt metabolism and ulti- 
mately, if not directly, upon the protein metabolism. We 
have evidence of the incomplete oxidation in the beta- 
hydroxybutyric and aceto-acetic acids, in the urine, and of a 
disturbed equilibrium in the increased ammonia and acidity 
of the urine. Such disturbances are experienced not only 
in fasting man but in diabetes, in which there is a failure to 
oxidize glucose, and they have been demonstrated experi- 
mentally by feeding a carbohydrate-free diet to men and to 
animals accustomed to a carbohydrate-rich diet. Acidosis 
increases the rate of protein metabolism. In fasting a fur- 
ther increase of protein metabolism results when the fat 
supply is reduced and the organism is forced to utilize pro- 
tein material as a source of energy. A measure of endo- 
genous metabolism cannot therefore be obtained by means 
of fasting experiments. 

A study of the metabolic changes on a protein-free diet 
containing carbohydrates, fats and salts in the proper pro- 
portions is perhaps a better index of the endogenous protein 
metabolism. This procedure is also open to question for 
under these conditions the body is supplying from its own 
tissues the protein material needed for repair. 



76 



PROTEIN REQUIREMENT 



Glutamic 




acid. 


Lysine 


43-7 


O.15 


26.2 





13.0 


3-03 


15.6 


6.00 


16.8 


6.00 


15-5 


7.60 


10. 1 


7-50 



Studies of the endogenous protein metabolism show that 
the average man metabolizes from 0.04 to 0.03 gram of 
nitrogen per kilogram of body weight — 2.1 to 3.8 grams of 
nitrogen for a 70-kilogram (154 lb.) man — in the form of pro- 
tein in the processes associated with the general wear and 
tear of the body. 

In constitution the protein molecule varies in both the 
quantity and the kind of amino-acids according to its source. 
If we compare the quantities of amino-acids in certain pro- 
teins we see that were a man to eat the vegetable protein 
gliadin alone he would have considerable more glutamic 
acid than was absolutely necessary and to obtain sufficient 
lysine to form a protein of the approximate composition of, 
say, beef protein he would have to ingest a much larger 
quantity of gliadin than beef or other animal proteins. 

Protein. 
Gliadin 
Zein 

Legumin 
Casein 
Gelatin 
Beef protein 
Fish protein 

The chemical structure of the protein ingested must there- 
fore be considered in determining the protein requirement. 
If the ingested protein contains a proportion of any essential 
amino-acid that is less than the quantity needed by the body 
or lacks the acid entirely, it becomes necessary for the body 
to synthetize the required amino-acid from other available 
acids or products, or to supply the amino-acid either by an 
increased ingestion of the protein itself, if the failure be due 
only to a lowered content, or by the ingestion of other pro- 
teins, or of the amino-acid itself if it be entirely absent. Con- 
versely, if the protein contain a greater proportion of certain 
amino-acids than the body can utilize they will not be used 
but deaminized, oxidized and the products excreted. 

Our knowledge of the synthesis of amino-acids in the body 
is very limited. Glycocoll is apparently synthetized and, 
under experimental conditions, perfusion of the liver, the 
formation of alanine, phenylalanine, and tyrosine have been 
demonstrated. The extensive synthesis of amino-acids in 
the body has not, however, been shown. Studies of such 
problems are complicated by the possibility that apparent 
synthesis may be due to the formation of the amino-acid by 
bacteria in the intestines and its subsequent utilization by 
the body. Synthesis of amino-acids with cyclic nuclei 



PRO TEIN REQ UIREMENT 77 

appears to be particularly difficult. The body cannot, then, 
be depended upon to supply the missing amino-acids ; they 
must be added to the diet as such or in the form of protein 
containing them. 

The fact that gelatin cannot of itself satisfy the total pro- 
tein requirement is due to its lack of the amino-acids, trypto- 
phan, tyrosine, and cystine. The addition of tyrosine and 
cystine and trytophan has been found to improve its value 
and make it satisfactory, for short periods at least. Exper- 
ments with growing rats have likewise served to demon- 
strate the effect of various quantities of amino-acids in the 
diet. A protein of corn, zein, which is deficient in the amino- 
acids, lysine and tryptophan, is found to be unable to sup- 
port growth or even to maintain the rats without loss of 
weight. With the substitution of equivalent quantities of 
other complete proteins the rats grow normally. The 
addition of tryptophan to the zein diet serves to maintain 
the rats without growth; while the addition of both trypto- 
phan and lysine makes the diet sufficient for both growth 
and maintainance. The importance of lysine for growth 
has been shown in experiments in which gliadin, a vegetable 
protein containing no lysine but tryptophan, was fed. The 
rats maintained their body weight but did not grow: the 
addition of lysine made the diet satisfactory. In one of 
Osborne and Mendel's experiments with gliadin a rat which 
failed to grow gave birth to a litter of young which grew at 
the normal rate on their mother's milk. Later these rats 
were fed different diets. Those which received complete 
proteins grew at the normal rate while one which received 
the diet fed to the mother failed to grow. From experiments 
of this nature carried out by Willcocks and Hopkins, Os- 
borne and Mendel, and Hart and McCollum, it has become 
evident that, other necessary factors being present, the ab- 
sence or a slight deficiency in the protein fed of an amino- 
acid essential in cellular metabolism, determines the extent 
of tissue construction, or rate of growth. With the absence 
of such units the other amino-acids which would have been 
used in the formation of a protein molecule cannot be utilized; 
they may be used in some processes in the formation of tissue 
or secretions not involving the missing radicle or are deami- 
nized and oxidized. McCollum has suggested that the pro- 
cesses of repair do not necessarily involve the decomposition 
and synthesis of an entire protein molecule. 

The quantity of protein needed also depends upon other 
factors in the diet. McCollum in studying the presence of 
toxic substances in natural foods (wheat) and their effect 



78 PROTEIN REQ UIREMENT 

upon growth found that protein tends to neutralize the effect 
of such substances. He explained his findings as follows: 
"A single factor (protein) in a ration may appear to admit 
the maximum performance of the animal with respect to 
growth, without itself representing the optimum amount or 
character. When this circumstance prevails it may entirely 
escape notice, yet if in another ration exactly like it, except 
that a second factor tends to injure the animal, nutritive 
failure may result. In such a case as the latter the improve- 
ment of the protein factor by the addition of more protein 
or by the substitution of a better protein, the plane of pro- 
tein intake remaining unchanged, the animal may make the 
maximum performance notwithstanding the unfavorable 
character of the injurious factor of the ration." This find- 
ing is an argument, in general, for a high rather than a low 
protein diet whenever the protein is not carefully selected. 

The addition of protein nitrogen in amounts equivalent to 
the basal nitrogen requirement, to a diet containing a suffi- 
cient quantity of fat and carbohydrate may not necessarily 
serve to prevent a loss of protein from the body. This may 
be due to the nature of the protein as already discussed, or 
to the number of portions into which the daily quota is sub- 
divided and ingested, in other words, the number of meals 
per day. Ingested protein is rapidly metabolized and there 
is little storage of protein or amino-acids in comparison to 
the reserves of fat and carbohydrate in the body. If the 
protein required for one day be ingested at one time a large 
proportion of it will be utilized or deaminized in from six 
to nine hours, and to satisfy the needs of the actively func- 
tioning tissues the body will draw upon its own protein re- 
serves. By taking the protein in smaller quantities a number 
of times a day the body will be more continuously supplied 
with the necessary amino-acids derived from its digestion. 
A similar effect can be produced in part by mixing the pro- 
tein with more or less indigestible material which apparently 
delays the digestion and absorption of protein. Nitrogen 
equilibrium has been maintained upon a diet low in protein 
when ingested in six equal portions which was not sufficient 
when ingested in three portions. 

The following studies by Thomas of the relative efficiency 
of protein in the maintenance of nitrogen equilibrium illus- 
trate the variable usefulness of different proteins. The 
basis of valuation of the food proteins is such that ioo re- 
presents protein which satisfies the basal requirement de- 
termined on a protein-free diet when fed in equivalent 
quantities — with ample quantities of carbohydrate and fat. 



PROTEIN REQ UI RE ME NT 79 

Biological Value of Proteins. 

Moat ' . . 104.7 

Milk 99.7 

Fish 94.5 

Rice 88.3 

Potato 78.9 

Bean 55.7 

Flour (wheat) 39-6 

Corn 2 9-5 

The high efficiency of meat protein has been ascribed by 
Thomas as due to the effect of extractives which may be con- 
cerned in the maintenance of nitrogen equilibrium. This is 
only one possibility for we know little of the relative struc- 
tures and combination of proteins in different foods or of 
associated factors, all of which might be effective. It is 
certainly true that animal proteins in general are more effi- 
cient in the human economy than vegetable proteins. 

Our discussion has confined itself more or less to partic- 
ular proteins. In the average diet a mixture of proteins is 
ingested so that the sum total is entirely sufficient for the 
needs of the body. In meat inefficient gelatin (collagen) 
occurs with the eminently satisfactory muscle protein, and 
likewise in corn the incomplete zein is associated with other 
proteins which contain the requisite amino-acids. Studies 
of the value of particular types of protein rich foods have 
indicated that a diet restricted to a single kind of seed (pea 
or bean), or grain, supplies protein of low biological value. 
Mixtures of protein from different vegetable products are 
better than the single food but no combination is superior 
to the milk proteins in supplying adequate protein (Mc- 
Collum). 

The protein requirement is influenced by the quantity of 
fat and carbohydrate, energy-yielding foods, present in the 
diet. The effect of these food-stuffs is to lower or raise the 
plane of protein metabolism when added or subtracted from 
a nitrogenous diet; fat is, however, less effective than carbo- 
hydrate. If the carbohydrates of a mixed diet, upon which 
nitrogen equilibrium is being maintained, be replaced by an 
isodynamic quantity of fat, a negative nitrogen balance will 
result; that is, the body will use some of its protein reserve. 
The replacement of fat by carbohydrate is accompanied by a 
lowered protein utilization. This is particularly true when 
the protein ingestion is low. When carbohydrates are fed 
to a fasting man or dog, or to one who is receiving a carbo- 
hydrate-free diet, either with or without protein, the rate of 
nitrogen excretion is lowered. Fat also is capable of reduc- 
ing the plane of nitrogen metabolism of a fasting organism, 



80 PRO TEIN REQ UIREMENT 

particularly when the subject is poor in fat. Variations of 
fat and carbohydrates within certain limits when both ap- 
pear in the diet at the same time do not result in marked 
variations in the protein metabolism. It may be that the 
failure of fat to maintain nitrogen equilibrium when it re- 
places carbohydrates is due to the fact that the body requires 
a certain amount of carbohydrate for its normal functioning 
and, that since fat apparently does not yield carbohydrate, 
and the amino-acids of the protein molecule may do so, the 
body breaks down an additional quantity of protein to fur- 
nish the necessary carbohydrate. Thomas has suggested 
that the beneficial effect of carbohydrate is concerned with 
the synthesis of amino-acid in the body. 

Lusk has suggested that 10 to 15 per cent, of the total 
energy requirement be in the form of protein. This applies 
approximately to people of all ages. For the average pro- 
tein requirement of man see the following discussion of stan- 
dard dietaries. 



STANDARD DIETARIES— AVERAGE PROTEIN 
REQUIREMENT 

Practically all the standard dietaries which have been pro- 
posed have been determined by the statistical method. 
Observations have been made of the quantity and kind of 
food ingested by a large number of persons under different 
circumstances; the composition of various kinds of food has 
been determined ; on the assumption that the results of these 
analyses approximate the composition of the food eaten in 
the dietary investigated, the amounts of protein, fat, and 
carbohydrate in the diet have been determined. Voit's 
standard was the first to attract widespread attention and 
it has been the nucleus of controversy concerning the opti- 
mum protein requirement for man. Voit proposed for a 
man at moderate work: 

Protein < 118 grams. 

Fat ....... ., 56 " 

Carbohydrate 500 " 

Total calories 3055 " 

Investigations of the dietary habits of groups of people in 
various countries and conditions have been the basis of other 
dietary standards. The following table contains some of the 
standards which have been suggested: 



STANDARD DIETARIES 



81 



at light 



Protein. 

gm. 


Fat, 
gm. 


Carbohydrate, 
gm. 


Fuel value 
Calories. 


150 
125 
IOO 






4IS0 
34OO 
2700 


90 






2450 


Il8 

145 

119 

IO7 

60 


56 

100 

51 

65 


500 
450 
531 
407 


3053 
3300 
3060 
2630 
2800 



Standard Dietaries. 

Author and conditions. 
Atwater (man) : 

Hard work . 

Moderate work 

Sedentary life 

Rest (or woman 
work) . 
Voit (Germany) : 

Average diet . 

Hard work 
Playfair (England) 
Gautier (France) 
Chittenden . 

From this table we see that the quantity of food in the 
form of protein, fat and carbohydrate varies with the kind 
and degree of work performed ; the amount of food required 
varies also with age, and with the sex of the individual. 

The influence of work upon the energy and protein re- 
quirements has been discussed in general. A greater con- 
sumption of energy-yielding material is required to satisfy 
the needs of a man at work than is required by a person at 
rest. This fact has been established by careful experiments 
in confirmation of the results obtained by dietary studies. 

External temperature also modifies energy requirements. 
A man exposed to the cold requires a greater quantity of 
energy-yielding food than the one who does the same work 
at a moderate temperature. For this reason studies of the 
daily habits of people of different climates show the ingestion 
of diets of different energy contents. Differences in the size 
and age of individuals involve diets of different energy con- 
tent. The infant has a higher energy metabolism than an 
adult in the prime of life; and an old man, a smaller require- 
ment. Two adults of the same size and weight, performing 
the same work, require approximately the same amount of 
energy. But where there is a difference in size, as in the 
case of a lean man and a fat man of the same weight, and 
approximately the same body surface, the energy require- 
ment of the thin man is much higher because of the greater 
mass of functioning tissue. 

To these physiological factors, which influence the energy 
requirement of man, the physical and economic factors must 
be added. Such considerations as taste, habit and custom, 
the kind of food available, and the ability to purchase, modify 
the quantity and kind of food eaten by any given group of 
individuals. Hence the standards based upon the study of 
the food consumption of various classes and races of people 
reveal not only the actual needs but also the habits and pro- 
pensities of the people. 



82 PRO TEIN REQ UIREMENT 

When considering the basal protein requirement of man 
we found that muscular activity had practically no effect 
upon the protein metabolism. An examination of the table 
containing the proposed standard diets of various investi- 
gators shows an increase in the quantity of protein where the 
fat and carbohydrate have been increased to meet the 
changed energy requirements. The studies on which these 
standards are based apply to men of different physique and 
muscular development, which difference is in itself reason 
for different amounts of protein in the diets. When it is 
considered, however, that the protein consumption of a man 
at moderate labor is already greatly in excess of his basal 
requirements, it is difficult to understand the reason for 
for large increases in the protein portion of the diet of indivi- 
duals at hard labor whose muscular development probably 
is not greatly increased. 

The increased production of heat (specific dynamic action) 
following the ingestion of protein, with the accompanying 
feeling of warmth is a partial explanation of the desirability 
of an increased protein ingestion by those exposed to cold; 
and, conversely, of the undesirability of a high protein diet 
in the tropical climates. The heat derived from such action 
of protein has been shown to be available for the mainte- 
nance of body temperature, but not for work. 

The optimum protein requirement of man has been a sub- 
ject of considerable controversy. The discussion concerns 
chiefly the standards which we have already discussed — 
approximately ioo to 150 grams of protein per day — and an 
amount considerably less than this, 50 to 75 grams of pro- 
tein per day. On the one hand there is evidence of the 
amount of protein which various peoples have been in the 
habit of eating and apparently crave. On the other hand 
there is a physiological basis for a low protein diet in that 
the minimal requirements of the average man are much 
lower than 100 grams of protein per day, that the body can 
satisfy its energy requirements with fats and carbohydrate 
and that the protein material taken in excess of the body 
needs is decomposed, and the nitrogen portion is excreted 
in the kidneys chiefly in the form of urea, while the carbon 
moiety is utilized for the production of energy. Chittenden 
has been the chief advocate of the low protein diet. Hind- 
hede, from his work on the use of the potato as the chief 
article in the diet, has recently advocated an even lower 
diet than that of Chittenden. 

Various arguments have been advanced for and against a 
low protein diet. Those who believe that such a diet is 



STANDARD DIETARIES 83 

advisable base their opinion, in addition to the facts indi- 
cated above, on observations which indicate that such a diet 
results in greater strength and endurance, is more economical 
and is accompanied by a lowered intestinal putrefaction. 
Against a low protein diet arguments have been presented 
to the effect that men do not eat a low protein diet from 
choice, that there is the danger of the selection of a diet with 
a low total caloric value, that the "minimum is not neces- 
sarily the optimum," and that low planes of mental, moral 
and physical development exist in countries in which the 
population subsist on a low protein plane. One of the most 
telling arguments in favor of a high protein diet where the 
nature of the protein and the qualitative nature of the diet 
is not known, is the finding of McCullom that an increase 
of the protein portion of a diet will in certain cases overcome 
the effect of toxic substances present in food. 

The values for the average protein requirement given in the 
table on page 81 have been determined chiefly by statistical 
means. The protein requirement is apparently not affected 
by as many variables as the energy requirement. Muscular 
work does not materially affect the protein metabolism 
provided the increased energy requirements are met with 
sufficient quantities of non-nitrogenous food-stuffs: fat and 
carbohydrates. When the body is already meeting a part of 
its energy requirements with protein material, such as might 
exist in underfeeding or in fasting, increased activity is asso- 
ciated with an increased protein destruction. There might 
in the course of time be an indirect increase in the protein 
metabolism following work as a result of an increase in the 
quantity of muscular tissue with its greater "wear and tear. " 

The protein requirement varies with the age of the indi- 
vidual considered. An infant, which is forming new protein 
as well as repairing the wear and tear of its body, requires 
proportionately more protein than does an adult who needs 
only to supply the protein for repair. An old man, with 
relatively diminished muscular development and tone, re- 
quires less protein material than the adult who is in the prime 
of his life. Muscular development undoubtedly affects the 
amount of nitrogenous material required; while the protein 
needs of the pregnant woman or nursing mother are increased 
because of the storage of nitrogenous material in pregnancy, 
and the drain upon the stored protein experienced during 
lactation. Although the average diet contains sufficient 
protein material to cover any variations in the requirements 
due to size, age, and sex, these factors must be considered 
when an insufficient or a restricted diet is prescribed. 



CHAPTER IV. 
INORGANIC SALTS, WATER AND VITAMINES 

The importance of inorganic salts has not been empha- 
sized in dietetics so much as the energy and protein parts of 
the diet. That this is so has been due in part to the fact 
that the average mixed diet contains a sufficient amount of 
the various inorganic constituents for all general purposes. 
Studies of pathological conditions, however, have repeatedly 
demonstrated that a diet may be entirely satisfactory from 
the stand-point of protein and energy and still be lacking in 
some inorganic constituent, or group of constituents, which, 
when supplied, rectified the trouble. Recent studies of the 
biological value of various foods and in the use of diets com- 
posed of purified food-stuffs in the study of the presence or 
absence of the vitamines have emphasized the importance of 
the necessity for the proper kinds and proportions of inor- 
ganic salts in the diet. In such work it has been found that 
an improper salt mixture may be as detrimental to growth 
as one which lacks other food factors, such as inadequate 
protein or the vitamines. 

A consideration of the role played by inorganic substances 
in nutrition will serve to bring out their importance in the 
dietary. Whereas fat, protein, and carbohydrate serve to 
furnish energy to the body, inorganic salts are not concerned 
directly with this. In their capacity, however, of regulating 
the body functions they contribute toward the oxidation of 
these various food substances. Iron in particular appears to 
be concerned in oxidation. We find this element in the red 
blood corpuscles as an important and apparently active con- 
stituent of the hemoglobin. Certain investigators have 
attempted to show that the action of oxidases is due to the 
inorganic elements or salts which are contained in them. 

The fluids and tissues of the body are maintained in 
osmotic equilibrium by the contained salts. The accumula- 
tion of water in one portion of the body or the desiccation in 
another is prevented by the diffusibility of salts or the at- 
traction for water when separated from the surrounding 
medium by a semipermeable membiane. When there is a 
perversion of this property by a change in the physical struc- 



INORGANIC SALTS, WATER, VITA MINES 85 

tures or the chemical properties we find pathogenic states to 
exist, such, for instance as the condition of edema. 

The inorganic elements occur in the body in two general 
forms: (a) Combined with organic material as such, as 
radicles or held in an insoluble form such as the iron of hemo- 
globin, the phosphorus of nucleoprotein, the iodine of the 
thyroid gland, and the constituents of the structural tissue 
and of all actively functioning tissues, e. g., the calcium and 
magnesium and phosphorus of the bone; (b) in solution as 
ionizable salts where they are active in maintaining osmotic 
equilibrium, and the constant reaction of the body fluids, 
assisting in the transportation of the oxygen and carbon 
dioxide in the blood, concerned in the permeability of the 
cell walls, and affecting the irritability of muscle and nerve. 

The mere enumeration of a few of the important uses of 
the inorganic element brings out strikingly their significance. 
The multiplicity of their function has likewise rendered the 
study of these substances difficult, for with one element 
having a varied function, its removal from the diet may be 
responsible for many secondary reactions which will mask 
the direct result. 

Experiments designed to show the effect of the complete 
removal of salts have demonstrated that an ash-free diet is 
detrimental to the organism. It was early shown that a 
diet containing the requisite amount of carbohydrate, fat, 
and proteid but which did not contain the ash constituents 
resulted in an early death. Von Bunge suggested that these 
harmful effects were due largely to an excess of acidic radicles 
present in the body caused by the sulphuric acid formed in 
the process of metabolism from the sulphur present in the 
protein molecule. Ordinarily this acid would be neutralized 
by the fixed bases present in the diet. In the absence of 
these, however, they derive a certain portion of their re- 
quired base from the alkali radicles in the tissues. He sug- 
gested the addition of carbonates to combat this acidity. 

Studies of the effect of an ash-free diet upon man have 
been made. In one case symptoms were experienced which 
were analgous to that associated with acidosis, including 
muscular weakness and the presence of acetone on the breath. 
Other investigators failed to obtain any symptoms of acidosis. 
In both experiments there was a loss of weight as the result 
of the ingestion of an ash-free diet. It is apparent that 
individual differences must be considered in the interpreta- 
tion of such data. With rats it has been found (Osborne 
and Mendel) that a fair amount of growth is attained in the 
absence of all but very minute amounts of the elements, 



86 INORGANIC SALTS, WATER, VITA MINES 

magnesium, sodium, potassium or chlorine but not in the 
absence of calcium or phosphorus. Sodium and potassium 
cannot both be absent from the diet at the same time. 

The analyses of various foods for the inorganic elements 
they contain, and a consideration of the latter on the basis 
of whether they yield ash which is predominantly acidic 
or basic in nature, have shown that some foods, upon oxida- 
tion in the body yield an excess of acidic over the basic 
elements, while of others the opposite is true. An excess of 
inorganic acid radicles in the blood, whether they occur as the 
result of the ingestion of the acids themselves or are produced 
in the processes of metabolism from neutral compounds, is 
neutralized in one of two ways — by combination (a) with 
ammonia or (b) with some of the fixed alkalies of the body. 
Since there is at all times an equilibrium, both changes occur. 
Such changes produce an excess of salts in the blood which is 
excreted in the urine. The fixed bases which accomplish 
this neutralization may come from the alkaline carbonates 
of the blood, perhaps from the calcium or magnesium of the 
bones. The ultimate result, if the diet be continued, is the 
reduction of the body's store of basic elements. Such a con- 
dition we have already considered in our discussion of the 
effect of a salt-free diet. The effect of an excess of basic 
elements in the body is not so serious, for they may be neutral- 
ized by the carbonic acid formed in the process of oxidation. 
The urine excreted after the ingestion of a diet which con- 
tains an excess of potential basic ash constituents will tend 
to be alkaline, while that obtained after a potentially acid 
diet will be acid. 

Sherman and Gettler have recently considered some of 
the more important foods on the basis of their acid- or base- 
yielding properties, and have called attention to the desir- 
ability of balancing potentially acid foods in the diet with 
predominantly base-yielding foods. The table on page 87 
gives the result of their work, grouped according to predomi- 
nating acid- or base-yielding power (extremes in each case). 

It will be seen in general that, with the exception of milk, 
animal products yield an excess of acid radicles whereas 
plant foods with the exception of cereals and some nuts 
yield an alkaline ash. Vegetables and fruits are chiefly base- 
yielding foods. That foods which are rich in the salts of 
organic acids should yield an excess of base is due to the fact 
that the acid portion of the molecule is oxidized in the body 
yielding carbonates which are potentially basic. 

Calcium, phosphorus, potassium, sulphur, sodium, lithium, 
chlorine, magnesium, manganese, iron, boron, iodine, fluor- 



CHLORINE REQUIREMENT OF MAN 



87 



Excess Acid or Base in Representative Foods in Terms 
of Normal Solutions. 1 



Article of food. 

Succulent vegetables 

Asparagus . 

Potatoes 

Carrots (or beets) 
Fruit: 

Cranberries 

Pineapple 
Nuts: 

Almonds 

Walnuts 
Legumes 
Cereal : 

Oatmeal (or wheat) 

Rice . . 
Lean meat 
Fish . . 
Milk . . 
Cheese . 
Eggs . . 



Potential acid. 
Per ioo Per ioo 

gm. calories. 



Potential base. 
Per ioo Per ioo 

gm. calories. 



0.8 

7.2 

10.8 



6.8 
12.0 
23-9 



1.8 



3-6 

8.6 
23-7 

3-8 

15-7 



6.9 



2.6 



ine and silicon are the more important "mineral" elements 
found in the body. The bases are combined chiefly as phos- 
phates, sulphates, chlorides, and carbonates. Of the chlor- 
ides in the body the sodium salt predominates. It is the 
most abundant inorganic constituent of the diet and also of 
the urine. The fluids of the body are particularly rich in 
sodium salts and, consequently, in sodium chloride; while 
the potassium salts predominate in the tissues, chiefly as the 
phosphates. The quantity of chlorides in the urine is 
directly related to that ingested, for the body tends to 
maintain itself in chlorine equilibrium. 



CHLORINE REQUIREMENT OF MAN 

The sodium chloride requirement of the body is difficult to 
determine. Studies of the minimum chloride requirement 
in which there is a complete removal of salt, as in fasting or 
an ash-free diet or sodium chloride-poor diet, fail to deter- 
mine the optimum requirement; they always show the low- 
est excretion under conditions in which the body has lost 
its reserve and is tending to conserve that amount which is 
left. Such studies on man indicate a loss of approximately 
10 to 12 grams of sodium chloride, calculated as chlorine, in 
the course of ten days. The daily excretion decreases 
gradually until it reaches a low level when between 0.1 and 
0.2 gram of chlorine are excreted per day. That, in such 

1 Compiled from Sherman: Food Products 19 15. Sherman and Gettler: 
Jour. Biol. Chem. 1912, xi, 363. 



88 INORGANIC SALTS, WATER, VITA MINES 



Chlorine Content of Foods. 

Per cent. Chlorine in Weight of 

of edible. ioo-Calorie ioo-Calorie 

portion. portion, gm. portion, gm. 

Protein-rich foods: 

Cheese I .o 0.2 23 

Chicken 0.6 0.02 45~93 

Beef and veal 0.5 0.05 35~50 

Cheese, cottage 0.5 .. 31 

Fish: 

Salmon 0.28 0.13 70 

Cod, haddock 0.24 0.33 216 

Egg white 0.15 0.28 196 

Milk, whole 0.12 0.17 145 

Milk, butter 0.10 0.275 280 

Egg, whole 0.10 0.06 68 

Egg, yolk 0.10 0.03 28 

Lentils 0.08 0.02 29 

Peanuts 0.04 0.007 18 

Peas, dried ...... 0.04 0.01 28 

Beans, dried 0.03 0.008 29 

Walnuts 0.01 0.001 14 

Carbohydrate-rich foods: 

Potatoes 0.12 0.10 81 

Flour, wheat 0.07 0.02 28 

Cornmeal 0.06 0.02 28 

Rice 0.05 0.01 29 

Oatmeal 0035 0.009 2 5 

Potato, white 0.03 0.04 120 

Barley, pearled 0.02 0.005 28 

Rye 0.02 0.005 28 

Honey 0.01 0.01 31 

Sugar 

Water- and salt-rich foods: 

Celery 0.17 0.9 540 

Lettuce 0.06 0.3 524 

Cauliflower 0.05 0.16 328 

Radish 0.05 o. 17 341 

Beets 0.04 0.08 217 

Carrots 0.036 0.078 221 

Rhubarb 0.035 0.15 433 

Cabbage 0.03 0.09 317 

Tomatoes .0.03 0.09 439 

Spinach 0.02 6.08 418 

Corn, green 0.014 0.014 99 

Cherries 0.01 0.01 128 

Grapefruit 0.01 

Grapes 0.01 0.01 104 

Lemons 0.01 0.02 226 

Oranges 0.01 0.02 195 

Peaches 0.01 0.02 242 

Peas, green 0.01 0.01 100 

Squash 0.01 0.02 217 

Beans, green 0.009 0.007 82 

Apples 0.004 0.006 159 

Fat-rich foods: 

Butter; lard; olive oil; salt pork; bacon; salt content, high and varies, 
6 



PHOSPHOR US REQ UIREMENT OF MA N 89 

case, chlorides have been lost beyond the reserve that is 
related to the quantity of chlorine ingested (which results 
in part from a lag in its excretion) is evidenced by the marked 
retention of chloride during the first days of feeding after a 
fast or after the ingestion of a salt-free diet. 

The sodium chloride requirement is affected by the nature 
of the diet. This is brought out most strikingly by a consid- 
eration of the quantity of sodium chloride taken by the her- 
bivora as contrasted with the carnivora. Von Bunge was 
the first to call attention to the fact that the carnivora do 
not exhibit the marked craving for salt that is evidenced by 
the herbivora. He ascribed this difference to the greater 
quantity of potassium salts ingested with a vegetable diet, 
which caused an increased excretion of potassium chloride, 
with the consequent depletion in chlorine. That potassium 
salts do cause an increased chlorine excretion has been shown 
by direct experimentation. From these considerations it 
is evident that the estimation of the quantity of sodium 
chloride required per day is a difficult matter. The quantity 
of chlorine necessary to protect the body against loss of 
chlorine has been placed at 3 or 4 grams per day. The 
average consumption has been estimated at from 15 to 20 
grams of sodium chloride per day. 

Ingestion of large quantities of sodium chloride increases 
the excretion of nitrogen. The explanation of this is not 
clear; it seems probable that it is due to the accompanying 
diuresis. 

The table on page 88 gives the average chlorine content of 
various foods arranged (1) according to whether they are 
particularly valuable as sources of protein, carbohydrate, or 
for the salts and water which they contain and (2) in each 
group in the order of their decreasing chlorine content. 



PHOSPHORUS REQUIREMENT OF MAN. 

Phosphorus 1 occurs abundantly in the body almost exclu- 
sively in the oxidized foim as the phosphoric acid radicle. As 
such, however, it appears in a variety of combinations. Thus 
it occurs in the body or in the combined form with the pro- 
tein molecule as nucleoprotein of the cell nuclei and as the 
phosphoproteins casein and vitellin; combined with fatty 
acids as lecithoprotein, the lecithins, and the phosphatides 
of the nervous tissue; in simple organic combination in the 

1 For a review of the metabolism of phosphorus the reader is referred to the 
excellent and complete review of the literature on this subject by Forbes and 
Keith: Ohio Agric. Exp. Sta., Tech. Bull., 1914, No. 5. 



90 INORGANIC SALTS, WATER, VITAMIN ES 

plant as phytin, and finally in the inorganic state combined 
with the various bases in the skeleton, particularly with 
calcium and magnesium and in the body in general as the 
sodium and potassium salts. 

As a constituent of the nuclei the phosphoric acid takes 
part in one of the most vital processes of the body, the forma- 
tion of new cells. Combined with calcium and magnesium it 
becomes the constituent which gives permanence and hard- 
ness to the bones, while as a soluble salt dissolved in the 
fluids of the body in conjunction with the carbonates and 
proteins it serves to maintain the neutrality of the tissues. 

The question of the ability of organic and inorganic phos- 
phorus to supply the body needs has been one which has 
received a great deal of attention. This problem is particu- 
larly important in connection with the artificial feeding of 
infants and the treatment of disease. The weight of the 
evidence shows that only a small amount of organically 
combined phosphorus is necessary in the diet provided a 
sufficient amount of inorganic phosphorus is present. Forbes 
has recently summed up the evidence with regard to the 
availability of organic and inorganic phosphorus. In his 
review of the factors which might affect the correct inter- 
pretation of the data considered — in which he calls attention 
to the fact, the importance of which has become daily more 
evident, that it is necessary to consider the presence or ab- 
sence from the experimental diet of such substances as the 
"vitamines" or lipoids (see p. 102) before we shall be able to 
demonstrate conclusively the greater advantage of one form 
of phosphate over the others or their equality, Forbes 
concludes with the following statement: 

"It therefore seems not at all unlikely that the many 
demonstrations of the superior nutritive value of organic 
phosphorus compounds have been influenced by other bene- 
ficial substances occurring in association with them in nat- 
ural foods, and contained as impurities in these organic phos- 
phorus compounds as isloated and used in nutrition investi- 
gations. As to the relative importance of this factor and 
others we are as yet unprepared to make positive assertions ; 
but these recent studies at least raise the question as to 
whether the apparent superiority of organic to inorganic 
phosphorus compounds is due to these organic compounds 
by themselves, or whether their superiority is dependent 
upon minute quantities of certain associated compounds. 
However this question may be settled the studies, certainly 
suggest that, if the natural organic phosphorus compounds 
are not of superior usefulness, or are not essential to the 



PHOSPHORUS REQUIREMENT OF MAN 91 

Phosphorus (P2O5) Content of Foods (Average Daily Requirement 

3.3 Grams). 

Per cent. P2O5 in Weight of 

of edible 100-Calorie 100-Calorie 

portion. portion, gm. portion, gm. 
Protein-rich foods: 

Cheese, hard .1.45 0.39 23 

Beans, dried . . . . . . 1 . 14 0.326 29 

Egg, yolk 1.0 0.27 28 

Peas, dried 0.91 0.24 28 

Peanuts 0.90 0.16 18 

Almonds . 0.87 0.132 15 

Beans, lima, dried .... 0.77 0.22 29 

Walnuts 0.77 0.11 14 

Lentils 0.66 0.29 29 

Cheese, cottage 0.50 0.40 31 

Meat and chicken . . . .0.50 (fat) o. 15-0. 18 45-93 

(lean) 0.24-0.30 

Fish 0.40 0.60 50 

Egg, whole 0.37 0.24 68 

Milk, whole 0.22 0.303 145 

Milk, skimmed 0.22 0.60 273 

Egg, white 0.03 0.05 196 

Carbohydrate-rich foods: 

Oatmeal, dry 0.827 0.216 25 

Barley, pearled 0.46 0.127 2 & 

Bread, whole wheat .... 0.40 0.16 39 

Cornmeal 0.30 0.08 28 

Potato, white . . . . . .0.14 0.166 81 

Rice 0.203 0.057 2 9 

Bread, white 0.20 0.075 39 

Wheat flour 0.20 0.05 28 

Potato, sweet 0.09 0.08 101 

Water- and salt-rich foods: 

Wheat bran 3.0 

Beans, green 0.27 0.22 82 

Peas, green 0.26 0.24 100 

Corn, green 0.22 0.21 99 

Cauliflower 0.14 0.45 328 

Spinach 0.13 0.54 418 

Beans, string 0.12 0.28 241 

Carrots o. 10 0.22 221 

Celery o. 10 0.54 540 

Lettuce 0.09 0.47 524 

Asparagus 0.09 0.39 450 

Cabbage 0.09 0.28 317 

Beets 0.09 0.19 217 

Squash 0.08 0.08 217 

Cherries 0.07 0.09 128 

Tomatoes 0.059 °- 2 57 439 

Oranges 0.05 0.09 195 

Peaches 0.047 0.11 242 

Apples 0.03 0.05 159 

Lemons 0.01 0.04 226 

Fat-rich foods: 

Cocoa 1.1 0.22 20 

Chocolate 0.90 0.14 16 

Cream 0.18 0.10 51 

Butter , , 0.03 0.004 13 



29 INORGANIC SALTS, WATER, VITA MINES 

maintenance of growth in animals, then other nutrients 
associated with them in the natural foods are essential, and 
the result is to put a new emphasis on the value of the nat- 
ural organic food-stuffs as compared with inorganic or 
artificially synthetized nutrients and certain manufactured 
foods." 

The phosphorus requirement of man has not been deter- 
mined with any certainty. The procedure is difficult be- 
cause, unlike many of the products of metabolism, a large 
proportion of the phosphorus may be excreted in the feces. 
The daily requirement of the adult man has been placed at 
1.44 grams of phosphorus (P) or 3.3 grams of P 2 5 . Under 
special conditions the requirement may be as low as 0.9 gram 
P or 2 grams of P 2 s . 

The quantity of food phosphorus that may be retained 
depends upon the nature of the diet. Since a large propor- 
tion is deposited in the bones, the presence of a sufficient 
amount of the bases, calcium and magnesium, associated 
with it in such structures is essential. When these are not 
present the phosphoric acid radicle is excreted in combina- 
tion with the more soluble bases and thus fails to satisfy the 
requirements. The ingestion or formation of acids or acid- 
yielding substances results in an increased excretion of phos- 
phorus. 

The phosphorus of the food, obtained as it is from both 
the animal and vegetable kingdom occurs in a variety of 
organic compounds, the particular advantage of any one of 
which has not been determined. Feeding experiments in 
which one type of phosphorus is fed to the exclusion of all 
others do not necessarily demonstrate the true availability 
of the compound. In selecting diets, then, for their phos- 
phorus content we cannot lay stress on any given food as 
presenting the constituents in a more available form than 
another. In considering data with regard to the P 2 5 con- 
tent of foods and particularly the vegetables, it is to be 
remembered that in their preparation a certain proportion 
of the phosphorus is removed. This is particularly true in 
the removal of the outer coating of cereals. 

The table on page 91 gives the relative quantity of P2O5 
in some of the more common foods. 

CALCIUM REQUIREMENT OF MAN. 

Calcium salts play a varied role in the body economy. 
Calcium occurs in the bones chiefly as phosphate. Dissolved 
in the body fluids calcium is an important factor in the 



CALCIUM REQUIREMENT OF MAN 93 

coagulation of the blood and in the contraction of the muscles. 
Underhill has suggested that calcium salts play an import- 
ant role in the regulation of the blood-sugar content. 

During the period of growth the importance of calcium 
salts is most easily demonstrated, for at this time the body 
is utilizing relatively large quantities of calcium, the removal 
of which from the diet at this time results in arrested or poor 
development of the bones. It is for this reason that consider- 
ation of the calcium requirement of the growing child is 
very important. The disease most commonly associated 
with calcium metabolism, rickets, may not be entirely the 
result of a lack of calcium in the diet but of a failure to as- 
similate it. In the adult the temporary removal of calcium 
is not followed by such marked effects as those observed 
in growth, for the body can call upon its reserve for a con- 
siderable time without showing any undesirable effect. 
Calcium, like phosphorus, is excreted largely through the 
intestine, and its excretion is continued in fasting. 

The importance of calcium and the fact that it is impos- 
sible to consider each salt by itself is well illustrated in the 
use of such solutions as Ringer solution and the antagon- 
istic action of salts. Physiological salt solution is sufficient 
to maintain the osmotic properties of muscle. In such a 
solution, however, muscle will not exhibit its properties of 
irritability and contractibility for any length of time. If, 
to the physiological salt solution, calcium and potassium 
chloride be added in the proper proportions, it will exhibit 
these properties for a much longer period; an isolated heart 
when supplied with oxygen will continue to beat spon- 
taneously for a long time in Ringer solution which contains 
these salts. An excess of calcium may produce a condition 
of tonic contraction called " calcium rigor." Loeb has re- 
cently shown that the ions antagonize each other in their 
their effect upon body processes; particularly the permea- 
bility of cell membranes. Membranes such as those sur- 
rounding sea-urchin eggs are permeable to certain concen- 
trations of sodium chloride and dilute acids. If to such 
solutions a bivalent ion, such as calcium or magnesium, be 
added the permeability is greatly reduced. Clowes has been 
able to produce results analogous to these in purely physical 
systems. Thus we see that the role of salts in the body, 
aside from their structural value is very complex. 

In discussing the cathartic action of salts, Meltzer calls 
attention to the fact that the salts of magnesium are essen- 
tially inhibitors of intestinal movement and suggests that the 
purgative effect produced by such salts is the result of the 



94 INORGANIC SALTS, WATER, VITA MINES 

combined action of sodium salts which stimulate contraction 
and of magnesium salts which cause a relaxation. This 
inhibitory effect of magnesium, which extends to other parts 
of the body, may be counteracted by subsequent injections 
of calcium salts. Anesthesia has been produced by the 
injection of magnesium sulphate. 

The calcium requirement of man varies with the period of 
life. The growing child requires a greater proportionate 
quantity of calcium per day than an adult in middle life; 
while an old man requires much less. During pregnancy 
and lactation there is a necessity for an increased consump- 
tion of calcium. Dietary studies show that an ingestion of 
approximately 0.7 gram of calcium (calculated as oxide) 
per day is the smallest amount which will maintain the 
average normal adult in calcium equilibrium on an ordinary 
diet. Since absorption is not always complete, a somewhat 
larger quantity is desirable, 1 to 1.5 grams per day. 

Whether or not the average mixed diet satisfies the cal- 
cium requirement without special selection of food is a matter 
which is open to question. When the food consists chiefly 
of meat and cereals, foods low in calcium, it is probable that 
the calcium ingestion is not sufficient. If the diet contains 
milk, eggs (yolk), legumes, and fruits the diet will probably 
contain a sufficient quantity of calcium. It has been found 
that, apparently, the calcium in vegetables is not as well 
utilized as that of milk or soluble calcium salts. In the 
absence of milk in the diet it would be best to augment the 
diet of children with soluble calcium salts rather than to 
rely entirely upon vegetables for this element (Mendel). 

The diet of pregnant and nursing mothers and of children 
requires special consideration. During pregnancy and lac- 
tation the mother is nourishing the young through her own 
system. At this time, too, there is an especial necessity for 
calcium and the other constituents which are concerned 
in the structural tissues of the body— magnesium, iron, and 
phosphorus. Forbes has recently shown that the cow when 
producing milk apparently draws upon her own calcium 
reserve, even though there be ample supplies of calcium in 
the diet. It is essential, then, that the mother have a plenti- 
ful supply of those foods which furnish these inorganic 
elements. Decay of teeth during pregnancy, has been 
ascribed to the drain upon the calcium reserves caused by 
the secretion of milk. 

The nature of the diet of a child is also important after it 
has ceased to depend upon its mother for food. Particular 
attention should be given to the calcium content of the food, 



CALCIUM REQUIREMENT OF MAN 95 

Calcium (CaO) Content of Foods (Average Daily Requirement 

i.o Gram). 

Per cent. CaO in Weight of 

of edible ioo-Calorie ioo-Calorie 

portion. portion, gm. portion, gra. 
Protein-rich foods: 
Cheese : 

Hard i.i 0.25 23 

Cottage 0.3 0.30 31 

Almonds 0.30 0.046 15 

Beans, dried 0.22 0.063 2 9 

Egg, yolk 0.20 0.05 28 

Milk, whole 0.168 0.24 145 

Milk, skimmed 0465 273 

Buttermilk 0.15 0.415 280 

Peanuts 0.14 0.04 18 

Lentils 0.12 0.04 29 

Walnuts 0.11 .. 14 

Beans, lima, dried . . . . 0.10 0.028 29 

Egg, whole 0.093 0.06 68 

Egg, white 0.015 0.028 196 

Fish 0.015-0.08 0.033 50 

Meat 0.01-0.03 0.005-0.01 45-93 

Carbohydrate-rich foods : 

Oatmeal 0.13 0.03 25 

Wheat 0.06 0.01 27 

Bread, whole wheat .... 0.04 0.016 39 

Bread, white 0.03 0.011 39 

Barley, pearl 0.025 0.007 28 

Potato, sweet 0.025 0.02 101 

Wheat flour 0.025 0.007 2 $ 

Potato, white 0.016 0.019 81 

Cornmeal 0.015 0.004 2 & 

Rice 0.012 0.003 2 9 

Honey 0.005 0.001 

Sugar 

Starch 

Water- and salt-rich foods: 

Cauliflower 0.17 0.55 328 

Olives 0.17 0.06 40 

Celery . o. 10 0.54 540 

Dates 0.10 0.03 . 29 

Spinach 0.09 0.37 418 

Beans, string 0.075 0.177 241 

Carrots 0.077 0.168 221 

Oranges . . . . . . . 0.06 0.11 195 

Rhubarb 0.06 0.26 433 

Lemons 0.05 0.12 226 

Lettuce 0.05 0.26 524 

Radish 0.05 0.17 341 

Asparagus 0.04 0.17 450 

Beans, lima 0.04 0.033 82 

Peas, green 0.04 0.032 100 

Beets 0.03 0.06 217 

Cherries 0.03 0.04 128 

Squash 0.02 0.054 2I 7 

Tomato 0.02 0.087 439 

Prunes (dried) 0.02 .. 33 

Apples 0.014 0.022 159 

Fat-rich foods: 

Cocoa 0.14 0.027 20 

Chocolate 0.14 0.052 16 






96 INORGANIC SALTS, WATER, VITA MINES 

for here the diet changes from one consisting of milk, which 
is richest in calcium, to a mixed diet which, unless properly 
chosen, may be poor in calcium. A calcium deficit for a 
growing child results in soft bones with the resulting ab- 
normalities of structure. 

The table on page 95 contains the more common foods 
arranged according to calcium content in each type group. 

IRON REQUIREMENT OF MAN. 

Iron occurs as a constituent of the blood pigment. We 
find it also in the chromatin of cells in which it is in part 
concerned, with the processes of oxidation, not only as a 
carrier of oxygen but as a catalyzer of enzyme action. The 
total quantity of iron in the body has been estimated at from 
3 to 4 grams. 

The iron requirement of man has been estimated at from 
0.01 to 0.012 gram of iron per day. Until a more careful 
determination of the actual requirements has been estab- 
lished a slightly higher value of 0.015 gram per day has been 
suggested (Sherman). Women require much more iron 
than men. During the periods of pregnancy, lactation and 
menstruation of women there is a considerable loss of iron 
which must be replenished and in the growth- period of 
children there is a greater demand for iron than in the adult. 
Observation has shown that the body is proportionately 
richer in iron at the time of birth than at any other time in 
its development. Analyses of milk and of the newborn and 
young have shown that during gestation the fetus accumu- 
lates a store of iron. During the suckling period the quan- 
tity of iron is almost constant and milk is comparatively 
poor in iron. The conclusion from these facts is, then, that 
the child derives from its mother, before birth, a store of 
iron sufficient for its needs throughout the period when it is 
nursing, and that the mother supplies, in the milk, approxi- 
mately enough iron to replace the iron lost in the processes 
of metabolism. After the child stops nursing it is important 
that the iron content of the diet be given careful considera- 
tion, for both the small daily losses made good by the milk 
and the iron needed for the processes of growth must be 
furnished. 

The degrees of availability of iron, in the organic and inor- 
ganic forms has been, as in the case of phosphorus, a matter 
of great controversy. Experiments have shown that both 
forms of iron are absorbed from the small intestines. That 
inorganic iron may be used in the production of hemoglobin 



IRON REQUIREMENT OF MAN 



9 



Iron (Fe) Content of Foods (Average Daily Requirement 0.015 Gram). 

Per cent, of Fe in ioo-Calorie Weight of 

edible portion. portion, gra. ioo-Calorie 

portion, gm. 
• Protein-rich foods: 

Lentils 0.0086 0.0024 2 9 

Egg, yolk 0.0085 0.0023 28 

Beans, dried 0.007 0.002 29 

Beans, lima, dried . . . 0.007 0.002 29 

Peas, dried 0.0056 0.0015 28 

Fish 0.004 0.0009 80-100 

Meat 0.0038 0.0008-0.003 35^50 

Egg, whole 0.003 0.0019 68 

Walnuts 0.0021 0.00029 14 

Almonds 0.002 0.0003 : 5 

Chicken 0.002 0.0013 45~93 

Peanuts 0.002 0.0035 18 

Milk, skimmed .... .. 0.00066 2-j^ 

Milk, whole 0.00024 0.00034 145 

Egg, white 0.0001 0.0002 196 

Carbohydrate-rich foods: 

Wheat 0.0053 0.0014 28 

Oatmeal, dry .... 0.0036 0.0009 2 5 

Bread, whole wheat . . 0.0015 0.0006 41 

Wheat, flour 0.0015 0.0004 28 

Barley, pearled .... 0.0013 0.00036 28 

Potato, white .... 0.0013 0.0015 I2 ° 

Cornmeal 0.0011 0.0003 28 

Honey 0.001 0.0003 3 1 

Bread, white .... 0.0009 0.0003 3 8 

Rice 0.0009 0.0003 29 

Potato, sweet .... 0.0005 0.0004 8l 

Water- and salt-rich foods : 

Dandelion greens . . . 0.027 0.0044 164 

Spinach 0.0032 0.0133 418 

Dates 0.003 0.001 29 

Olives 0.0029 0.0009 33 

Beans, lima 0.0025 0.002 82 

Beans, string .... 0.0016 0.0038 241 

Peas, green 0.0016 0.0016 100 

Cabbage 0.0011 0.0035 317 

Asparagus 0.001 0.0043 45° 

Lettuce 0.001 0.005 5 2 4 

Carrots 0.0008 0.0016 221 

Corn, green 0.0008 0.00075 99 

Squash 0.0008 0.0017 217 

Beets 0.0006 0.0013 217 

Lemon 0.0006 0.0013 226 

Radish 0.0006 0.002 341 

Celery 0.0005 0.0027 54° 

Cherries 0.0005 • • I2 8 

Turnips 0.0005 0.0013 254 

Tomato 0.0004 0.0017 439 

Apples 0.0003 0.0005 J 59 

Oranges 0.0003 0.0006 195 

Peaches 0.0003 0.0007 242 

Onions .. 0.0011 205 

Fat-rich foods: 
Butter 

Cream .. 0.0001 51 

Cocoa ...... . . o . 0005 20 

7 



98 INORGANIC SALTS, WATER, VITA MINES 

has not been proven, it does increase the production of hemo- 
globin, in which case it apparently acts as a stimulant to 
the cellular activities. Iron in simple organic combination, 
lactate, has been used successfully as the source of iron for 
growing rats. There is ample evidence that iron was found 
in organic combination is assimilated and used in the pro- 
cesses of growth and in the formation of hemoglobin. Al- 
though inorganic iron appears to be as effective as organic 
iron it has been recommended by some that at least a part 
of the iron ingested being the "organic" form. Iron is elimi- 
nated chiefly in the feces. The table on page 97 contains 
thejron content of some of the more important foods. 

In using the table it is essential to remember that fat meat 
contains a smaller proportion of iron than does a lean piece, 
for fat contains practically no iron. The preparation of 
cereals for the market (milling) results in the removal of a 
considerable portion of the iron contained in the whole 
grain. The advantage of foods, such as vegetables and fruits, 
which are not particularly valuable to the body for protein 
or a source of energy, is shown when it becomes desirable 
to increase the inorganic salt content of the diet. 

IODINE REQUIREMENT OF MAN. 

Iodine is present in its greatest amount in the thyroid 
gland. The function of iodine in the thyroid is not known. 
The quantity of iodine in the gland is variable. Ingestion 
of iodine or the application of iodine to the skin is accom- 
panied by an increased iodine content of the thyroid. It 
appears to be in combination with protein material. The 
name thyroglobulin has been given to an iodine-rich protein 
isolated from the thyroid gland. Regions in which the 
iodine content of the water is low have been shown to be, in 
many cases, those in which goiter is prevalent. If, as gen- 
eral observation seems to indicate, there is a relation between 
the lack of iodine and the prevalence of goiter, it is import- 
ant to know the foods which contain iodine. 

Iodine is contained in the water of various districts; it 
also occurs in sea water and in foods grown near the sea. 
Recent analyses of foods have shown that iodine is not a 
constant constituent of foods; that when present it is usu- 
ally found in exceedingly minute proportions, and that in 
general, at least, it must be regarded as an accidental constit- 
uent in the sense of standing in no vital relation to the 
growth of food products. The presence of iodine in most 
vegetable food products clearly depends upon the fact of its 



WA TER REQ UIREMENT OF MA N 99 

presence in the soil and the lack of a selective capacity in the 
feeding of plants. 1 Of the plants examined, Irish moss, 
from which blanc mange is prepared, and agar agar are the 
best sources of iodine. Garden vegetables, some kinds of 
legumes, or seeds, beans, and peas, are shown to be fair 
sources of iodine, although the presence or absence of iodine 
and the quantity contained are uncertain. Studies of foods 
from different sections of the country, particularly from local- 
ities in which goiter is prevalent, failed to show any uniformity 
in the presence of iodine over districts which were compara- 
tively free from goiter. 

WATER REQUIREMENT OF MAN. 

Water as an essential constituent of the diet receives very 
little attention in the usual consideration of the foods. That 
this is so is but natural, for it is one of the most readily 
obtainable and generally used food-stuffs. The lack of water 
is, however, sooner and more keenly felt than the absence of 
protein, carbohydrate, or fat. An animal receiving neither 
food nor water will die sooner than one which is given only 
water; while an earlier death will result from dry food and no 
water. 

The relative importance of water from a quantitative 
point of view is indicated by the water content of the body 
tissues. The fat-free organs show a comparatively constant 
water content, being about 80 per cent. The presence of 
fat affects the percentage of water content of the tissues as a 
whole, but being inert so far as holding water is concerned, 
it does not appear to influence extensively the composition 
of the tissues which hold it. The secretions are particularly 
rich in water (86 to 99 per cent.), while the skeletal tissues, 
such as bone and connective tissue, have a much lower 
water content (10 to 50 per cent.). The tissues of young 
animals, of regenerating and probably of recuperating tissues 
are richer in water than those of an adult organism. 

The functions of water are numerous: it is a constituent of 
all protoplasm; as a solvent it aids in carrying to the cell 
the food material produced by digestion in the removal of 
the waste products; it maintains the osmotic equilibrium 
between the various organs and tissues; by reason of its 
high specific heat its evaporation assists in the maintenance 
of a constant body temperature ; and it is the vehicle for the 
transportation of the blood elements throughout the body. 

Cameron: Jour. Biol. Chem., 1914, xviii, 335. Forbes and Beegle: Jour. 
Med. Research, 1916, xxxiv, 445. 



100 INORGANIC SALTS, WATER, VITA MINES 

The water present in the body is not necessarily to be 
considered as free water in the sense that after its complete 
removal from the cellular structures they will not cease 
their activities or that its return will initiate them anew. A 
certain amount of water is probably held in loose chemical 
combination or by physical attraction with the various 
molecular structures, such as the protein. It is known that 
much of the organic material in the body exists in swollen 
colloidal masses and that the removal of water from them 
affects their physical and perhaps their chemical properties. 
Our knowledge on this point is rather meagre. We do know, 
however, that the complete removal of water results in the 
disappearance of the phenomenon known as life. Since the 
water content of various tissues is relatively constant a 
decided diminution in the water content is fatal. Certain 
organisms, such as the frog, insects, etc., can lose a consider- 
able proportion of their water under favorable conditions 
and still remain alive, although usually dormant; seeds 
exhibit similar phenomena. Water is never entirely absent 
under such conditions; there is a minimum which if passed, 
results in the disappearance of life. 

Water is ingested either as such or associated with food. 
Most water contains a considerable quantity of salt. 1 The 
quantity of water ingested with the food may be considerable ; 
many foods are roughly three-fourths water. A certain 
amount of water is liberated in the tissues as the result of 
oxidation. 

The quantity and manner in which water is excreted is 
affected chiefly by the temperature and humidity of the sur- 
rounding air, the activity of the individual and the quantity 
and nature of the food and water ingested. Under normal 
conditions the equivalent of the water ingested in a day is 
excreted in a similar time chiefly through the lungs and skin, 
and in the urine and feces. A considerable proportion of 
the water ingested under average conditions of temperature 
and humidity appears in the urine within a comparatively 
short time after its ingestion. After large volumes of water 
have been taken as much as three-fourths of the amount 
appears in the urine within an hour after its ingestion. 
Higher temperatures outside the body, or excessive muscu- 
lar activity increase the loss of water through the lungs and 
skin; while with low temperatures and relative quiet the 

l The. specific effects of certain mineral waters is due to their salt content. 
It may be, however, that the increased water ingestion, under such circum- 
stances which usually accompanies the use of such waters, may also contribute 
to the beneficial effects of water cures. 



WA TER REQUIREMENT OF MAN 101 

amount of water which appears in the urine is increased. 
Twenty-five per cent, of the heat lost from the body in a day 
has been found to be through the evaporation of water — at 
approximately the rate of 29 grams per hour or 700 cc. per 
day. With an increase in the quantity of water ingested, 
other conditions being the same, a greater proportion of the 
ingested water appears in the urine. The body may suffer 
a loss of water as the result of excessive perspiration, the 
action of diuretics or of cathartics. Under such circum- 
stances the ingestion of water results in a restoration of the 
amount lost, for the tissues tend to maintain the concentra- 
tion of water at a constant level. 

With the loss of water there is usually a loss of salt from 
the body either in the urine or through the skin. One inves- 
tigator has studied this loss with regard to increased perspira- 
tion and the processes attending the restoration of water. 
He suggests that thirst resulting from excessive perspiration 
is quenched most readily by water containing salts, or taken 
with food, than with distilled water; for unless salt is present 
the water ingested will not be retained but will be rapidly 
excreted. In the process of recuperation following emacia- 
tion there is a very rapid restoration of the lost water. Thus 
the tissues of fasting animals, which show an increased water 
content, upon the ingestion of food and water, even though 
large quantities of water have been ingested throughout the 
fast, show a marked water retention. Because of the varied 
activities of man the quantity of water which is necessary for 
the normal functioning of the body is a difficult matter to 
determine. It has been placed at from 2 to 5 liters (or 
quarts) per day. 

The effect of water on metabolism has been studied from 
many angles. Ingested water passes rapidly through the 
stomach and is readily absorbed in the intestines. In spite 
of this it has been shown that it affects the rate and extent 
of digestion. Water taken into the stomach in large quanti- 
ties increases the secretion of gastric juice; small amounts 
have no effect. When water is taken with food the flow of 
gastric juice has been shown to be not only greater in amount 
but to contain more acid. The secretion of bile and pan- 
creatic juice is also stimulated by water, probably because 
of the interrelation between the acid reaction in the stomach 
and the flow of these secretions. The passage of food from 
the stomach has been held to be accelerated as the result of 
the ingestion of water. This is not entirely correct, for it 
has been shown that there is a slight retardation of the 
passage of bread from the stomach when water is taken after 



102 INORGANIC SALTS, WATER, VITAMINES 

bread. Experiments with fistulous animals and anatomical 
and x-ray studies have shown, however, that water, when 
ingested alone, does not mix to any extent with the food 
mass in the stomach in its passage to the pylorus. A sort 
of trough is formed along the lesser curvature of the stomach 
through which the water flows from the esophagus to the 
pylorus. Practically neutral water has been observed to 
pass the pylorus when the stomach is full of food and the 
digestive processes are at their height. 

A large ingestion of water serves to increase the excretion 
of nitrogen in the urine. This effect is the result apparently 
of stimulated cellular activity and in part to a flushing out of 
the soluble nitrogenous end-products of metabolism. 

Mattill and Hawk have studied the influence of copious 
water drinking with meals and found a more complete utiliza- 
tion of food, protein, carbohydrates, and fat and decreased 
putrefaction and bacterial development in the feces. From the 
results of such work we may conclude that for the normal 
individual the ingestion of water with meals is not harmful. 

VITAMINES OR ACCESSORY FOOD-STUFFS 

Investigations of the dietary factors concerned in growth 
and of certain diseases, such as beri-beri and scurvy, have 
shown that for normal growth and maintenance of health 
and. of weight at least two substances are necessary in a diet 
in addition to (a) an adequate protein or mixture of proteins, 
(b) a proper combination of inorganic salts and (c) energy 
(obtained from carbohydrate, protein or fat) in amounts 
sufficient to meet the needs of the body. The quantities 
of these substances required for normal nutrition are ex- 
ceedingly small. Their identification is not on the basis of 
their chemical composition — they are apparently not pro- 
tein, fat or carbohydrate in nature— but through their 
effects upon the growth and health of animals or individuals 
when known to be absent or when added to a deficient diet. 
Various names have been applied to these unidentified 
dietary essentials such as, vitamines, accessory factors, food 
hormones, growth determinants, growth stimulants, body 
regulators, etc. The term vitamine has become rather 
generally used as a class name for these substances both in 
the scientific and popular literature and this term will be so 
used in our discussions. 

Vitamines occur in both plants and animals but appear to 
be present in greater concentration in some foods than in 
others. While these substances are present in animal tissues 



VITA MINES OR A CCESSOR Y FOOD-STUFFS 103 

animals are unable to synthetize them and are, therefore, 
dependent upon plants or other animals as their source of 
vitamines. Two types of unidentified substances or vita- 
mines have been detected and a third appears probable. 
The first vitamine, designated fat-soluble A, is soluble in 
fats and accompanies them when isolated from food-stuffs. 
It is associated with fats particularly those obtained from 
the tissues and organs of both plants and animals rich in 
cellular material, such as butter fat (milk), egg yolk, kidney 
fat, cod liver oil, etc., from animals and the leaves of plants — 
alfalfa, spinach, celery tops, chard, dandelions, beet tops, 
lettuce, cabbage, etc. Extracts of spinach leaves have been 
found to be exceedingly rich in this substance. Those por- 
tions of plant and animal life which serve as places for the 
storage of reserve food material such as the fatty tissue and 
muscle tissue of animals and the fleshy portion of oily fruits 
and the seeds of plants — olives, peanuts, cotton seeds — or 
the carbohydrate rich (starchy) portions of plants and 
seeds, — tubers, roots, stalks, endosperm of seeds, etc., — are 
comparatively poor in fat-soluble A. The products obtained 
from these portions of the plants and starch, sugars, wheat 
flour, degerminated corn meal, polished rice, olive oil, cotton- 
seed oil, peanut oil, etc., are practically lacking in this sub- 
stance. Fat-soluble A is relatively thermo-stable although 
purified products rich in it appear to lose their activity as 
the result of keeping or heating for long periods. 

The second unidentified food factor, water-soluble B is, 
as the name implies, soluble in water; it is also soluble in 
alcohol. This substance is widely distributed in both plant 
and animal foods, milk, eggs, meat and vegetables — leaves 
and entire seeds, grains, roots and tubers. It is not associa- 
ted with the fats or oils extracted from foods. As in the case 
of fat-soluble A this substance is most abundant in cellular 
rich structures of plants and animals. Thus the outer coat- 
ing and germ of seeds and grains, yeast, glandular organs, 
etc., are rich in water-soluble B. Products obtained from 
the storage portions of grain by milling, lack, or are very poor 
in this second factor — white flour, polished rice, degerminated 
and bolted corn meal. Water-soluble B is not completely 
destroyed under ordinary conditions of heating, as in cooking 
and preserving, provided the solution or material is not 
made alkaline, such as by the addition of soda. The origi- 
nal vitamine of Funk, the anti-neuritic vitamine is the same 
as water-soluble B of McCollum. 

The third vitamine, the anti-scorbutic vitamine, has only 
recently been established as an entity. Fresh foods, partic- 



104 INORGANIC SALTS, WATER, VITAMINES 

ularly fruits and vegetables, and meat and milk are capable 
of curing scurvy. Drying or cooking for long periods at 
comparatively high temperatures diminishes or destroys the 
curative property. 

A full recognition of the ex-istence of such accessory sub- 
stances has come through two channels in particular, the 
study of deficiency diseases, such as beri beri and scurvy, and 
qualitative studies of the diet, in which the rate of growth 
and increase in body weight are taken as the criteria of its 
sufficiency or insufficiency. As an example of the first class 
of work we may take beri beri. In considering the diet of 
individuals susceptible to beri beri it was noted that those 
living largely upon polished rice were more susceptible than 
those ingesting a diet of unpolished rice. It has been shown 
further that when chickens or pigeons are fed on polished 
rice they develop polyneuritis, a disease similar to beri beri, 
while those fed unpolished rice do not do so. They have, 
therefore, been used extensively in the study of substances 
capable of curing beri beri. Analysis of rice polishings has 
shown them to be richer in phosphorus than other parts of 
the grain. Yet attempts to associate beri beri with phos- 
phorus metabolism have had little success beyond showing 
that the accessory substances occur in those parts of grains 
rich in phosphorus. The injection of an alcoholic or water 
extract of rice polishings, of certain plants or of animal 
organs into birds affected with polyneuritis will bring about 
rapid recovery. Funk has made attempts to isolate the 
substance which is the active factor in such cures. He has 
obtained from rice polishings and autolyzed yeast a crystal- 
line product possessing the property of curing polyneuritis 
even when given in as small quantities as a few milligrams. 
The exact nature of the material is unknown. Funk pro- 
posed the name vitamine for substances capable of curing 
" deficiency" diseases and suggests that it contains nitrogen 
of the amine type and that it is related to the pyrimidine 
nucleus. The substance prepared by Funk is soluble in 
water and alcohol, insoluble in ether, chloroform, benzene, 
and acetone; is destroyed by alkalies, but is more stable in 
the presence of acids; heat, that is by boiling for some time, 
destroys it. It is readily absorbed by silicious earth, fuller's 
earth, or Lloyd's reagent, . and extracts prepared by this 
method have been found to be quite effective. 

Williams 1 has studied the effect of certain hydroxypyridine 
derivatives upon birds afflicted with polyneuritis gallinarum 
in an attempt to determine the nature of the vitamine of 

1 Tour. Biol. Chem., 1916, xxv, 437. 



VITA MINES OR A CCESSOR Y FOOD-STUFFS 105 

Funk. He found partial curative effects less satisfactory 
than the natural "vitamine" preparation with one of the 
isomeric forms of hydroxypyridine, while another isomer was 
entirely ineffective From this and other considerations 
Williams came to the conclusion that isomeric changes are 
at least partially responsible for the instability of " vita- 
mines" in food-stuffs and that anti-neuritic properties may 
be related to certain types of isomerism. This work is 
suggestive but has not been fully substantiated. 

The second source of our knowledge of accessory sub- 
stances, studies in which the rate of growth has been taken 
as a criterion of the sufficiency or insufficiency of a given 
diet, has perhaps been more fruitful than the study of dis- 
eases in extending our conception of their relation to nutri- 
tion in general. Such studies were initiated originally to 
learn the effect upon nutrition of variations in the amounts 
and kinds of amino-acids in the diet. It was in the selection 
of a suitable diet consisting of simple purified food substances 
which would form the basis for subsequent variations in the 
diet that the importance of accessory substances for growth 
became evident. 

It has been shown (Hopkins and Wilcox; McCollum and 
Davis; Osborne and Mendel) that when rats are fed on a 
practically fat-free diet, composed of protein (such as casein 
or edestin), starch, and a suitable salt mixture which was 
entirely sufficient with regard to its energy, protein, and salt 
content, they did not grow normally, nor did they maintain 
their weight. The addition of lard to this diet yielded 
slightly better but still unsatisfactory results. When, how- 
ever, milk was added to the mixture containing lard, growth 
would continue. In studying the constituents of milk 
which were responsible for this correction in the diet it was 
found that butter would accomplish the same result. 

To determine which constituent of the butter carried the 
accessory substance, the butter fat was separated from the 
other constituents, protein, salts, and water, by centrifugal- 
izing warm butter. When this purified butter oil, a sub- 
stance practically free from nitrogen and phosphorus, was fed 
the results were just as satisfactory as those obtained from 
ordinary butter, indicating that the active agent was con- 
tained in butter fat. This substance (or substances) is resis- 
tant to heat and a certain amount of chemical action for 
butter which has been heated with live steam or subjected to 
the process of saponification does not lose its efficiency. 
When kept for long periods of time products rich in fat- 
soluble A tend to decrease in potency. The fats closely 



106 INORGANIC SALTS, WATER, VITAMINES 

associated with metabolic activity are more effective in 
maintaining growth than "storage" fats, lard, beef fat, 
etc., which are in general ineffective or less satisfactory. The 
substance contained in butter fat remains efficient for over 
a year; while "butter oil," in which it is more concentrated, 
begins to lose its efficiency in half a year and becomes en- 
tirely inefficient in a year, even when kept at o° C. and in 
the dark. Egg yolk fat, cod-liver oil, kidney fat, the ether 
extract of ripe cod testicle and forage plants also supply the 
substances necessary for growth. The liquid portion of 
beef fat obtained by fractional crystallization from alcohol 
will accomplish similar results. Certain fats, such as lard, 
olive oil, cold pressed almond oil, the more solid portions of 
beef fat obtained in the preparation of beef oil, as indicated 
above do not contain this substance or substances. The 
deficiency is not due to a lack of the lipoids, lecithin and 
cholesterol, for phosphorus-containing substances are practi- 
cally absent from butter oil, and lard contains a greater 
amount of cholesterol than butter. This active material 
bears certain quantitative relations to the diet, for there is a 
minimum value which must be present to produce results. 

The presence of a water-soluble accessory factor was de- 
monstrated (McCollum) through the case of diets in which 
lactose was substituted for dextrin in an otherwise complete 
food mixture. With such a substitution the diet was not 
effective in promoting growth. The addition of the water 
extract of egg yolk or the alcoholic extract of wheat germ to 
such a defective diet was sufficient to correct it. This led 
them to believe that lactose carried a water-soluble factor 
and that there were two factors necessary for growth in addi- 
tion to the customary food-stuffs. Investigations of various 
lactose preparations served to confirm the suspicion with 
regard to the presence of the water-soluble factor and it has 
since been demonstrated in a number of foods. 

Further studies have brought out with renewed emphasis 
the variety of factors which must be considered and con- 
trolled in the regulation of the diet and the possibility and 
the danger of neglecting modifying factors in our zeal to 
correct the most apparent defects. "A moderate shortage 
of one or another of the chemically unidentified dietary 
factors" is not to be regarded "as of greater gravity than 
faulty character in any other dietary factor." (McCollum.) 

A toxic factor may influence the dietary value of a food. 
The relative biological values of foods has recently been 
emphasized by McCollum. Foods are divided into two 
classes (a) those particularly rich in vitamines, adequate 



VITA MINES OR A CCESSOR Y FOOD-STUFFS 107 

protein and salts, protective foods, which include milk, egg 
yolk and the leaves of vegetables (b) foods deficient in one 
or more particular, which include all other foods such as the 
endosperm of seeds and grains, meat, roots and tubers. 
The protective foods are those which are particularly rich 
in cellular material whereas the other foods represent the 
portions of plants and animals which serve as storage tis- 
sues. It has been found that in the case of rats, a diet contain- 
ing a proper supply of protein, energy, salts, and "fat-soluble 
A" and " water-soluble B" may be apparently satisfactory 
for growth and reproduction, while a diet composed of 
naturally occurring food-stuffs may be inadequate because 
of the presence of a substance or substances which exert a 
toxic influence upon the body, but if to such a diet a sub- 
stance containing a toxic substance be added, a failure to 
continue to grow may result. If, however, the protein por- 
tion of the diet be increased or a better, more complete pro- 
tein be substituted, the animal may continue to grow at a 
normal rate. The disturbances in metabolism accompany- 
ing a diet containing a large proportion of the wheat germ is 
apparently, in part, deficient because of the presence of a 
toxic substance. 

Scurvy. — - Scurvy has been recognized for many years as 
a disease associated with diet. It has been found to occur 
under conditions in which there was an absence of fresh 
fruit, vegetables and meat. Scurvy has occurred in the 
early days when sea-going vessels were required to remain 
out for long periods of time, in sieges, following crop failures 
and in arctic expeditions, i. e., under conditions in which 
the diet was restricted to preserved foods or very limited 
quantities of fresh foods. The addition of fresh foods or 
fruit juices served to cure or prevent the disease. It has 
occurred recently in the war in Europe among troops sub- 
sisting largely upon a limited dietary. Scurvy in infants is 
sometimes recognized as a separate disease from that occur- 
ring in adults. Since infantile scurvy is referable to the 
same dietary defects which cause scurvy in adults and the 
symptoms are in general the same it is probably similar. 

The subject of scurvy has received considerable attention 
recently in its relation to the vitamines and, as the result of 
the war and limited food supplies, with regard to the anti- 
scorbutic properties of various foods and the effect of heat 
and preservation on these properties. Scurvy has been held 
to result from (a) a limited consumption of potassium, 
particularly the "acid vegetable potassium," (b) infection 
following a deficient diet, (c) acidosis following the ingestion 



108 INORGANIC SALTS, WATER, VITAMINES 

of a preponderance of acid yielding foods, id) the absence of 
some dietary factor which leads to the development of sub- 
stances in the intestines and these in turn are the cause of 
the symptoms (autointoxication), (e) stasis in the large in- 
testine as a result of the physical character of the diet and 
the production of toxic putrefactive products and (f) the 
absence of a specific vitamine. Recent controversy has in- 
volved particularly the last three factors. 

Following the demonstration of a vitamine in connection 
with beri beri, Hoist and Frolich and also Funk came to the 
conclusion that scurvy was a deficiency disease in the same 
sense in which beri beri is a deficiency disease, i. e., there 
was a substance involved in the etiology of the disease of the 
nature of a vitamine. The deductions were based upon the 
similarity in the way beri beri and scurvy are produced by 
the ingestion of one-sided diets, particularly those derived 
from milled products in contrast with whole grains and seeds 
or fresh foods, and their cure by the addition of such foods. 
Furthermore, grains which would produce scurvy in guinea 
pigs would when sprouted prevent the occurrence of the 
disease. The guinea pig was used to study the anti-scorbutic 
value of foods. The findings confirmed the observations on 
men in that fresh, raw, or boiled succulent vegetables are 
anti-scorbutics. Fresh raw milk was an anti-scorbutic but 
heated milk was not. Boiling of vegetables diminished the 
anti-scorbutic value. Extracts of vegetables would cure 
scurvy and if acidulated with citric acid did not lose their anti- 
scorbutic value when heated as readily as the natural ex- 
tracts. Extracts of acid fruits and vegetables were more 
resistant to heat with regard to their ability to cure scurvy 
than the non-acid foods. 

The work of Hoist and Frolich, then, tended to indicate 
the presence of a substance of the nature of a vitamine. 
Subsequent data seemed, however, to discountenance such 
a conclusion. Jackson found that guinea pigs would develop 
experimental scurvy in various degrees on diets of pastuer- 
ized, raw, boiled, skimmed and condensed milk, as well as 
after the ingestion of grains. The presence of bacterial 
infection was demonstrated in the swollen joints which she 
held to be specific for the disease. Soon after this McCollum 
and his co-workers maintained that while scurvy in guinea 
pigs was due to a faulty diet the effects were not due to the 
absence of a specific substance but to constipation associated 
with the physical character of the diet which resulted in the 
accumulation of toxic fecal products. They based their 
conclusions upon a series of observations; (a) that the oat 



VITA MINES OR A CCESSOR Y FOODSTUFFS 109 

kernel contained all the food factors necessary for the growth 
of rats when corrected with purified foods for its deficiency 
in certain inorganic salts, fat-soluble A, and the character 
of the protein ; (b) in the course of their autopsies the ceca 
of guinea pigs fed on oats or milk and oats were impacted 
with putrifying feces; (c) the addition of inert liquid petro- 
latum to the diet of oats and milk would check the disease 
in certain animals in which it was well developed and phenol- 
phthlein, another laxative, would prevent the occurence of 
the disease over long periods; (d) an artificial orange juice, 
composed of citric acid, cane-sugar and inorganic salts, 
exerted a decided protective action when added to the oat- 
milk diet. These workers were not ready entirely to accept 
the bacterial infection theory of Jackson and proposed an 
alternative hypothesis in which they held that bacterial 
infection was probably secondary to the injury of the intes- 
tinal walls through the formation of bacterial toxins as the 
result of putrefaction in the impacted cecum. 

These conclusions of McCollum were radical and yet 
attractive in their simplicity. Evidence was soon presented 
from many sources, Chick and Hume, Harden and Zilva, 
Mendel, Hess, Givens, Emmett and others tending to dis- 
credit the interpretation of certain of McCollum's findings. 
It was found that in studies of experimental scurvy the 
quantities of foods ingested must be taken into consideration. 
Raw milk, which serves as an anti-scorbutic for infants and 
which did not serve as such for guinea pigs on the oat-milk 
diet, was found to be capable of preventing scurvy if fed in 
sufficient quantities. Instead of lacking the anti-scorbutic 
factor it was merely low in its anti-scorbutic value. Sub- 
stances which will prevent impaction of the feces in the 
guinea pig did not prevent scurvy when added to diets 
which produced scurvy in their absence. Artificial orange 
juice, similar to McCollum's preparation was found to be 
inefficient nor did the removal of citric acid and other acids 
from lemon juice render it inactive. Fuller's earth which 
absorbs the water-soluble B vitamine does not absorb the 
anti-scorbutic factor. Water-soluble B can be removed from 
a mixture which contains both vitamines. 

McCollum has recently repeated much of the work of the 
investigators mentioned above and his own work in which 
he has also measured the quantities of food consumed and 
has modified his views 1 so as to recognize a protective sub- 
stance against scurvy. His observations on the curative 

1 Private Communication, June, 19 19. 



110 INORGANIC SALTS, WATER, VITAMINES 

effect of petroleum oil and phenolphthlein were doubtless 
due, as Harden and Zilva stated, to the fact that the appe- 
tite of the animals, which were furnished a diet of milk and 
oats, fell off because of infection of the cecum, and when the 
intestinal canal was cleaned out by the laxatives they took 
sufficient milk to have a curative effect. 

The evidence is, then, that there is a protective substance 
or vitamine active against scurvy as well as one for beri 
beri and for xerophthalmia. 

The anti-scorbutic vitamine has been found in green leaves, 
fresh fruit juices, onions, root vegetables (swedes and potatoes), 
fresh milk, meat and sprouted seeds. The different foods 
show variations in their content of the vitamine. Orange 
juice or a water extract of orange pulp, 2:1, lemon and lime 
juice, have been found to be particularly active. Hess found 
that a slightly alkalinized solution of orange juice, if injected 
soon after preparation, is an effective anti-scorbutic. In gen- 
eral, however, alkaline extracts deteriorate rapidly. Tomato 
juice, fresh or canned, and potato water have been found 
to be good anti-scorbutics for children. Hess noted a case 
of scurvy which did not react to orange juice but did to potato. 

Foods which have been found to be low in their anti-scor- 
butic value or lack the vitamine are: yeast and its extracts, 
wheat embryo, egg yolk, prunes, beets, cod liver oil, olive 
oil, "malt soup," (unless prepared from fresh raw milk) and 
dried foods or foods cooked for a long time. Desiccation 
tends to reduce the content of the anti-scorbutic vitamine in 
foods, least apparently in acid foods. There is some evi- 
dence that the method of drying and the age of the fresh 
food has a relation to the degree of destruction of the vita- 
mine. Cooking, heating, or boiling, to ioo° C. tends to 
destroy the anti-scorbutic vitamine; cooking vegetables for 
a short time at a high temperature is not as destructive as 
subjection to a low temperature for a long period. 

Milk has already been referred to as an anti-scorbutic. 
In comparison with oranges, however, it is relatively poor 
in the vitamine. The effect of heat upon milk is to lower 
or to destroy the anti-scorbutic property. According to 
Hess the aging of milk with the subsequent development of 
an abnormal flora is an important factor in the destruction 
of the anti-scorbutic factor, more so perhaps than heating. 
Milk heated to 145 F. or boiled milk is less apt to produce 
scurvy in infants than milk which has been heated to 165 F. 
The explanation is that boiling tends to destroy all bacteria 
and heating to 145 F. does not destroy all of the lactic acid 
producing organisms, which are in a sense protective against 



VITA MINES OR A CCESSOR Y FOOD-STUFFS 1 1 1 

the growth of putrefactive organisms. Milk heated to 145 
F. will not sour unless reinoculated with the lactic acid 
bacillus. Raw milk kept for some time tends to lose its 
anti-scorbutic value. Dried milks and evaporated milks 
lack the anti-scorbutic vitamine. There is some evidence 
that dried milks made from fresh raw milk exposed to re- 
latively high temperatures for a short time may retain a 
part at least of their anti-scorbutic value. 

Pellagra. — Pellagra is held to be a disease resulting from 
a lack of a specific substance of the nature of vitamines in 
the diet, arising from an improper selection of foods or loss 
of the vitamine in cooking. It still appears possible that 
the effect of diet is only secondary in that the deficient diet 
may be a predisposing factor to infection due to decreased 
resistance. 1 According to Goldberger 2 pellagra is due di- 
rectly to a faulty diet as the result of one or a combination 
of the following factors, (a) a physiologically defective pro- 
tein supply, {b) a low or inadequate supply of fat soluble 
vitamine or of water-soluble vitamine, (c) a defective mineral 
supply. McCollum after analyzing various supposed pel- 
lagra producing diets finds them generally deficient in the 
character of the protein, fat-soluble A, calcium, sodium and 
chlorine. 

Rickets. — The status of rickets as a deficiency disease has 
not been established. The evidence of Hess in which cod- 
liver oil was found to prevent the occurrence of rickets 
among negro children and the experiments of Mellanby who 
was able to prevent experimental rickets in pups with meat, 
water extract of meat free from protein, malt extract, com- 
mercial yeast extract, large quantities of milk, butter, mar- 
garine or cod-liver oil, whereas the protein of meat, casein, 
linseed oil, or yeast would not do so, tend to indicate the 
necessity for the presence of some particular dietary factor. 

^'lacNeal; Jour. Am. Med. Assn., 1916, xvil, 975; Jobling and Peterson: 
Jour. Infect. Dis. 1916, xviii, 501. 

2 Jour. Am. Med. Assn. 1918, lxxi, 944. 



CHAPTER V. 

FOOD REQUIREMENTS IN PREGNANCY AND LAC- 
TATION. FOOD REQUIREMENTS AND FEED- 
ING OF CHILDREN. FASTING. 

FOOD REQUIREMENTS IN PREGNANCY AND LACTATION 

During pregnancy food is required for the development and 
maintenance of the fetus, and associated tissues, growth 
of the uterine musculature, body musculature and of the 
breasts as well as for the maintenance of the maternal organ- 
ism itself. In certain stages of gestation additional food is 
required to meet the extra calls upon the mother. In the 
early stages of pregnancy food beyond that normally re- 
quired by the mother, is not needed since the food required 
for the growth and maintenance of the embryo is compara- 
tively small. Later, however, from about the middle of the 
period of gestation, the embryo and associated tissues begin 
to make considerable demands upon the mother and pro- 
vision must be made in her diet for these purposes. Follow- 
ing parturition the additional demands upon the maternal 
organism continue but the method of nourishing the young 
is transferred from the continuous nourishment through the 
blood stream to intermittant feeding through the breasts. 
The mother must still maintain herself but the quantity of 
tissue to be maintained is lowered to the extent of the special 
tissues elaborated in the body for the proper growth of the 
embryo; a difference which is not great. 

Energy.— In the early stages of gestation there is little 
increase in the energy requirement of the mother plus the 
fetus. During the last stages of pregnancy an extra meta- 
bolism has been determined equivalent to approximately 
four per cent, of that of the mother in sexual rest. This 
extra metabolism represents the additional energy necessary 
to maintain the child and the associated tissues. Studies 
of the respiratory quotient of the fetus indicate that heat 
is produced largely from carbohydrate. Following parturi- 
tion the total metabolism of the mother and infant is almost 
exactly that which existed before parturition. In other 

Purlin, Amer. Jour, of Obstetr., 1917, lxxv, 913, has discussed the data with 
regard to the metabolism of mother and offspring. 



PROTEIN REQUIREMENT 113 

words, the extra metabolism of the child required to main- 
tain itself outside its mother's body is approximately that 
of the additional tissues associated with the fetus in utero. 
The demands made upon the mother soon after parturition 
are no greater than those just beforehand. As the child 
grows and requires more food, the added energy require- 
ments must be met to compensate for the milk produced. 
The heat production of puerperal women was found to be 
1 1 per cent, higher than the average for non-pregnant women 
and seven per cent, higher than that of the same subjects 
just before delivery. This difference in the rate of meta- 
bolism has been ascribed in part to the increased activity 
of the mammary glands and in part to the stimulating effects 
of the products of involution. 

The energy metabolism of the infant soon after birth is 
slightly lower, per unit of body surface, than that of the 
mother. This is due possibly to the undeveloped heat 
regulating mechanism. From the time of birth the rate of 
metabolism increases until a maximum is reached between 
one and two years; during the time of most rapid growth 
and maximum milk consumption. Following this the rate 
of metabolism decreases rapidly at first and then more 
gradually (adult) until old age with a slight rise at the time 
of puberty. The basal metabolism of an infant at birth is 
48 Calories per kilogram of body weight. Between six and 
twelve months the basal metabolism is 60 calories per kilo- 
gram. Severe crying increases the metabolism 40 per cent, 
per hour. Fifteen per cent, of the calories ingested are re- 
tained for growth. The energy intake for infants to cover 
the basal metabolism and increase for activity and growth 
has been placed at from 80 to 90 Calories per kilogram of 
body weight. 

Protein Requirement. — Data with regard to nitrogen meta- 
bolism in pregnancy indicate a negative nitrogen balance 
during the early stages of gestation. Such a loss takes place 
in animals no matter what the nature of the diet may be, 
indicating that this loss is not essentially a matter of the 
quantity of food. The limited data with regard to human 
metabolism does not demonstrate a negative balance but 
does show a lower positive balance at the corresponding 
stage of gestation than at any other time. This tendency 
toward a negative balance occurs at about the third month 
of gestation; the time of placental formation and morning 
sickness. With the completion of the placenta this increased 
catabolism gives place to predominant anabolic activity. 
From this time on we find a retention of nitrogen for the 



114 FOOD REQUIREMENTS IN PREGNANCY 

growth of the fetus and development of the maternal tis- 
sues. Retention of' nitrogen from the seventeenth week 
to the end of the period of gestation is greater than the re- 
quirement of the fetus, associated tissues and the mammary 
glands. The increased retention of nitrogen has been sug- 
gested as being in anticipation of the demands of labor and 
the period of lactation. The quantity of nitrogen retained 
by the fetus has been estimated by Michel: 

Composition of the Fetus. (Michel, After Murlin.) 

Age, weeks. N. grams. P. grams. Ca. grams. Mg. grams. 

16 2.94 0.66 0.42 0.02 

20 6.05 1.45 2.21 0.08 

24 11.05 2. -44 408 0.13 

28 16.01 3.53 5.88 0.19 

40 72.70 18.67 33 26 0.82 

The data indicate very clearly, the fact that the greatest 
quantitative growth takes place in the last fourth of preg- 
nancy. During this period particularly it is necessary that 
the diet of the mother be adequate with regard to inorganic 
salts as well as other foods; milk is one of the best single 
foods for this purpose. 

Immediately following the birth of the child the mother 
exhibits a negative nitrogen balance arising chiefly from the 
involuting uterus. When these processes are practically 
completed the positive balance present in the later stages 
of gestation is again found. 

The character of the protein ingested is of importance in 
pregnancy and lactation. The maternal system cannot 
synthetize amino-acids to any extent, hence it is necessary 
to provide adequate protein to meet the increased draft 
imposed by the growing infant. A deficient diet reacts 
more upon the mother than upon the child. During gesta- 
tion the fetus draws upon the resources of the mother for 
the food factors necessary for growth. Under- feeding has 
been found to have little effect upon the young. This 
applies particularly to under-feeding following the normal 
full development of the mother before becoming pregnant. 
Long continued under-nutrition during the period of growth 
of the mother and subsequent pregnancy has been found to 
interfere with the normal processes of gestation or to result 
in inferior young. The same conditions apply to lactation; 
the tendency is to continue to produce a normal milk in 
spite of under-nutrition. If, however, the period of under- 
feeding is sufficiently prolonged the quantity of milk appears 
to diminish rather than the proportions of the constituents 
present. In any case the mother is the first to suffer and 



DIET AND LACTATION 115 

afterward, when her tissues fail, the young. As McCollum 
has expressed it — the mother is the factor of safety in the 
nourishment of the young. 

The extra demands upon the maternal body for inorganic 
salts during pregnancy and lactation are confined chiefly to 
calcium and phosphorus, i. e., the mother ordinarily takes 
with her food sufficient of the other inorganic salts, sodium, 
chlorine, iron, magnesium, etc., to meet her own needs and 
those of her child. The quantities of calcium and phos- 
phorus needed for the production of the fetus and later of 
milk are rather large. The data of Michel indicates a 
large retention of calcium in the last quarter of the period 
of gestation. At the beginning of lactation in such high 
milk producing animals as the cow there is a loss of calcium 
(Forbes) from the body of the mother which cannot be off- 
set, at the time, by an increased consumption of calcium. 
In the later stages of lactation and after milk production 
has ceased the loss of calcium from the body is probably 
replaced. 

Diet and Lactation. — The relation of the diet to the 
quantity and quality of milk produced is of considerable 
importance. The original stimulus to the milk flow origi- 
nates in the placenta or associated tissues. Later (Eckles), 
this stimulus loses its force and is replaced by a nervous 
stimulus. The flow of milk is maintained and apparently 
may be increased to a maximum for the individual through 
the constant stimulus of nursing or the removal of the milk. 
The extent to which milk flow can be increased by nursing 
is not known. Observations have been made in which it 
was increased in wet nurses from the quantity necessary for 
one child to that sufficient for three children. 

Diet has little effect upon the composition of milk during 
the early stages of lactation. 1 Over- feeding has practically 
no effect. If the stimulus to produce milk is not present 
feeding will not increase the quantity of milk. The con- 
sumption of large quantities of nitrogenous food will not 
affect, appreciably, the percentage composition of milk. 
Under-nutrition does not affect the quantity of milk pro- 
duced for some time ; the percentage of fat tends to decrease. 
In this case the milk is produced at the expense of the mother. 
Later in the period of lactation the effect of under-nutrition 
is to reduce the quantity of milk and to cause some modifi- 
cation in the percentage of fat (increase) and protein and 
lactose (decrease). If under-nutrition is sufficiently pro- 

x The composition of milk varies slightly according to the stage of lactation. 



116 FOOD REQUIREMENTS OF CHILDREN 

longed the character of the milk is undoubtedly affected. 
Recent work on the distribution and occurrence of the vita- 
mines has shown that the animal organism apparently can- 
not synthetize these food factors but must obtain them, 
ultimately, from plant sources. Where the store of vita- 
mines in the mother is low her milk will tend to be defi- 
cient in these substances. Women with beri beri have been 
found to produce a deficient milk such that normal infants 
allowed to nurse develop beri beri. Experiments with rats 
indicate that the milk is deficient in vitamines when the 
diet of the mother lacks these substances. There is some 
indication that the quantity of vitamine in cow's milk is 
related to the nature of the diet. 

The quantity and quality of the diet necessary for human 
milk production has been studied by Hoobler. For women 
performing light work diets containing 2600 to 2900 calories 
per day maintained a better milk flow without affecting the 
maternal tissues than those consuming a diet of from 3400 to 
3700 calories. Where the mother is engaged in more active 
work a slightly higher diet would be indicated. Over feed- 
ing did not result in an increased milk flow. The best re- 
sults were obtained with a ratio of protein calories to fat 
(calculated as carbohydrate) and carbohydrate calories of 
1 : 6. This is rather a high protein diet. Animal protein 
was found to be better than vegetable protein for the pro- 
duction of milk. A combination of nut protein and vege- 
tables gave very satisfactory results. Milk as a source of 
protein is the best for the production of milk and the protec- 
tion of the maternal tissues. 

FOOD REQUIREMENTS AND FEEDING OF CHILDREN. 

Children differ from adults in that they are in the process 
of growing; they are daily increasing the size of their muscles, 
bones and organs and are also very active. The food of a 
growing child must meet not only the daily wear and tear and 
furnish energy for the daily activities but it must supply addi- 
tional quantities of all types of food-stuffs for use in the 
formation of the increasing mass of tissue. The rate of 
increase in weight for boys and girls is given in the table 1 
on page 117. 

The rate of increase in weight is not uniform but proceeds 
in cycles. Robertson 2 has shown from an analysis of the 
rate of growth that the increase in weight is periodic, in the 

1 Manny, from data obtained by Holt, Burke and Boas, Pub. 115, New York 
Association for Improving the Condition of the Poor. 
2 Amer, Jour. Physiol, 19 15, xxxvii, 37. 



ENERGY REQUIREMENTS OF CHILDREN 117 



form of S-shaped curves. For man there is, (a) probably 
a short cycle preceding the implantation of the ovum, (b) 
a second cycle beginning with the development of the em- 
bryo and extending nearly to the end of the first year of 
extra-uterine life with a maximum velocity at 1.66 months 
in the male and 2.47 months in the female, (c) a third cycle 
starting during or near the completion of the first year of extra- 
uterine life and practically fusing with the preceding cycle with 
the maximum rate at about 5.5 years for both sexes, (d) a 
fourth cycle which attains its maximum velocity at 14.5 
years for females and 16.5 years for males and ending with 
the attainment of adult weight. 

Average Weight, and Increase in Weight per Year for Boys and Girls. 



Boys 



Girls 



Age 




Increase 






Increase 




Weight 


per year 


Weight 


per year 




lbs. 


lbs. 


lbs. 


lbs. 


Birth 


7-55 




7. 16 




6 months 


16.00 


16.90 


15 


50 


16.68 


1 year 


20.50 


900 


19 


80 


8.60 


2 years 


26.50 


6.00 


25 


50 


5-70 


3 


31.20 


4.70 


30 


00 


4-50 


4 " 


35 00 


3-8o 


34 


00 


4.OO 


5 yrs. 6 mos. 41 .20 


4.14 


39 


80 


3-87 


6 




45 • 20 


4.OO 


43 


40 


3.60 


7 


1 


49 5o 


4-30 


47 


70 


4-30 


8 


' ' 


54 -50 


5 00 


52 


50 


4.80 


9 


' ' 


59 • 60 


5.10 


57 


40 


490 


10 


' ' 


65 40 


5.80 


62 


90 


550 


11 


1 ' 


70.70 


5-3o 


69 


50 


6.60 


12 


' 


76.90 


6.20 


78 


70 


9.20 


13 




84.80 


7.90 


88 


70 


IO.OO 


H 


1 ' 


95.20 


10.40 


98 


30 


9.60 


15 


' ' 


107.40 


12.20 


106 


70 


8.4O 


16 


1 ' 


121 .00 


13.60 


112 


30 


5.60 



When the food supply is restricted in amount growth is 
retarded particularly with regard to weight. In experi- 
mental animals it has been noted that when restricted to 
diets adequate in the nature of the constituents but inade- 
quate in amount such that they maintain a fairly constant 
weight that they grow in length and height but become 
emaciated. If after such a period of feeding an adequate 
diet is given the animal will gain in weight and in circum- 
ference and will return approximately to normal provided 
the restriction has not been too prolonged. Such recovery 
has been noted in children. 

Energy Requirements of Children. — The basal metabolism 
of children is higher than that of adults. The variation in 
the basal metabolism with age for male subjects is given in 
Fig. 2, p. 62. From the chart it is evident that from birth 
to approximately five years of age the rate of metabolism is 



118 FOOD REQUIREMENTS OF CHILDREN 

increasing. From five years on until maturity the rate of 
metabolism falls with a slight rise at about the thirteenth 
to fourteenth year, puberty, after which it continues to 
decrease. Following the attainment of maturity the basal 
metabolism shows a gradual and regular decrease until 
death. The data are not complete for female subjects but the 
general trend of the curve is the same except that the values 
are slightly lower. In addition to the increased rate of 
metabolism of children over that of adults we find an in- 
creased rate of energy consumption as the result of marked 
activity. It is evident, therefore, that children require food 
out of proportion to their size when compared with adults. 
Girls are both smaller and less active than boys and they 
require less food. The following table gives the difference 
in total calories for boys and girls in given age-groups and 
the calories per pound for boys and girls from three types of 
study of the metabolic requirements of children. 1 

Difference in Total Calories Consumed by Boys and Girls at 
Different Ages. 

2-s years. 6-9 years. 10-13 years. 14-17 years. 

Boys and girls 1308 1718 2190 2525 

Boys 1309 1797 2337 2534 

Girls ....... 1245 1575 2015 2253 

Boys and girls, protein, grams 47 57 68 90 

Calories per Pound for Boys and Girls from Each of Three Types 
of Metabolic Data. 

Boys Girls 



Age 


Dietary 




Respira- 


Dietary 




Respira- 


group 


Expts. 


Metabolism 


tion Expts. 


Expts. 


Metabolism 


tion Expts 


Years 




Expts. 








Expts. 




2-5 


38.7 


44.I 


6l 


9 


35-0 


42.8 




6-9 


32.8 


36.9 


49 


6 


32.8 


34- 1 


49 6 


0-13 


30-9 


27.8 


38 


7 


25.O 


27-3 


33-2 


4-17 


28.2 


29. I 


26 


9 


20.5 


20.0 


26.9 



From a consideration of the data available with regard to 
the energy requirement of children Miss Gillett has pre- 
pared the table on page 119 giving the caloric intake required 
by children of different ages. In this table allowance is made 
for individual variation. Boys have been found to ingest 
food equivalent to 4000 to 5000 calories per day. 

Protein Requirement. — Less is known with regard to the 
protein requirement of children than that of adults. It 
appears that protein calories to the extent of 10 to 15 per cent, 
of the total calories is sufficient; this is the proportion found 
for adults. Such a proportion of protein amounts to a re- 

1 Gillett; Food Allowances for Healthy Children, Pub. 115, New York Assoc . 
for Improving the Condition of the Poor, 19 17. 



PROTEIN REQUIREMENT OF CHILDREN 119 

latively high protein intake per unit of body weight when it 
is considered that the caloric intake of children is from two 
to three times that of the resting adult, 

Food Allowances for Children (Gillett)- 

Calories per Day. 
Age, Boys. Girls. 

Years. 

Under 2 900-1200 900-1200 

2-3 1000-1300 980-1280 

3-4 1 100-1400 1060-1360 

4-5 1200-1500 1 140-1440 

5-6 1300-1600 1220-1520 

6-7 1400-1700 1300-1600 

7-8 1500-1800 1380-1680 

8-9 1600-1900 1460-1760 

9-10 1700-2000 1550-1850 

10-11 1900-2200 1650-1950 

11-12 2100-2400 1750-2050 

12-13 2300-2700 1850-2 150 

13-14 2500-2900 1950-2250 

14-15 2600-3100 2050-2350 

15-16 2700-3300 2150-2450 

16-17 2700-3400 2250-2550 

The character of the protein ingested is of as great import- 
ance in growth as the quantity of protein. The nature of 
protein deficiencies has been discussed on page 76. Data 
obtained on the biological value of proteins, complex foods 
and vitamines in which growth is the index of the relative 
value of various foods have contributed many interesting 
and important facts with regard to food requirements in 
growth. Milk protein was found by McCollum 1 to be of 
greater value for the purposes of growth in the pig than 
certain cereal. proteins. The following table contains a protion 
of the data. 

Per cent, of Ingested Protein Retained for Growth by the Pig. 

Per cent, of 
Source of protein. protein retained. 

Milk . 63 

Oats, rolled 26 

Wheat 23 

Corn 20 

Meat undoubtedly has a value approximating that of milk. 
It is to be remembered that the growth impulse of the pig 
is much greater than that of the human infant and the 
capacity to store protein in the latter case, is, therefore, 
less. Similar relative values have been obtained with re- 
gard to milk protein in experiments on rats. The lower 
value of vegetable proteins for growth and maintenance is 
not to be construed as meaning that they are not valuable 

^our. Biol. Chem., 1914, xix, 323. 



120 FOOD REQUIREMENTS OF CHILDREN 

sources of protein. The work of Mendel and Osborne has 
repeatedly shown that the limiting- factor in the inefficient 
protein is the low content or absence of one or more amino- 
acids. A combination of two proteins when either alone 
would be insufficient may be entirely satisfactory. This is 
possible since the deficiencies in amino-acids are different 
for different proteins and that one protein may contain an 
excess of an amino-acid in which another protein is deficient. 
All animal proteins ordinarily used for food may be considered 
as relatively complete proteins; gelatin is an exception. In 
using a large proportion of vegetable foods it is necessary 
to correct for the low biological value of these proteins. 
Milk is the best source of protein for this purpose in the diet 
of children, not only because of the high value of its protein 
but because of the associated food constituents which it 
contains, calcium salts and the vitamines. 

Inorganic Salts. — Our knowledge of the quantities of in- 
organic salts required for growth is rather limited. Those 
salts needed in the greatest quantities are, calcium, phos- 
phorus, iron, sodium and chlorine. With the exception of 
sodium and chlorine these are the elements most likely to be 
deficient in the diet. Ample quantities of milk and vege- 
tables will ensure an adequate consumption of the necessary 
inorganic salts. Milk supplies calcium and phosphorus, but 
little iron, the vegetables, particularly leafy vegetables, 
furnish iron in addition to the other salts. The infant when 
subsisting entirely on milk apparently depends upon its 
reserve of iron in its tissues until it is past the nursing stage 
and can obtain iron from other foods. Insufficient inorganic 
salts will result in a retardation of growth. That this is not 
true for limited periods has been shown by Mendel and 
Osborne who observed normal growth in rats on diets bal- 
anced with regard to acid and base but poor in sodium, 
potassium, magnesium or chlorine, but not when deficient 
in calcium or phosphorus. 

Vitamines. — The subject of vitamines has been discussed 
page 102. It is in the feeding of children that particular 
attention must be given to the question of vitamines. An 
ample supply of all three types of vitamine should be assured 
fat-soluble A, water-soluble B, and the anti-scorbutic vita- 
mine. Water-soluble B is rather widely distributed in 
nature and is fairly resistant to drying and preserving. Un- 
less the diet is restricted to highly milled or purified foods 
there is little danger of a failure to obtain this anti-neuritic 
vitamine. Fat-soluble A is less widely distributed and more 
consideration must be given to its presence in the diet. 



FOOD FOR CHILDREN 121 

This vitamine is found particularly in milk fat (butter) and 
organ fats, as distinct from body fats and vegetable fats, 
and in the leaves of vegetables. It is resistent to heat but 
apparently undergoes deterioration upon long standing. 
Particular attention must be paid to the presence of the 
anti-scorbutic vitamine in the feeding of small children. 

Water. — Children need a plentiful supply of water. It 
has been found that an adult man will lose 25 per cent, of 
his daily heat production through the evaporation of water 
from the skin and lungs. Children with their marked activity 
and higher rate of metabolism will certainly equal if not 
surpass this figure. The necessity for water is, therefore, 
evident. 

Selection of Diets for Children after the Second Year. 1 — 
In feeding children during the period of growth the import- 
ant considerations are (a) that the diet be selected to furnish 
the necessary food factors, (b) that the food be wholesome 
and plentiful, and (c) that good food habits are established 
and maintained. In selecting foods, milk, eggs, cereals, 
vegetables and fruits, should form the basis of the diet; 
meat should be served only occasionally and in small amounts. 
Methods of cooking should be confined entirely to boiling, 
roasting and baking; no fried food should be served. Cer- 
eals should be thoroughly cooked, preferably the night be- 
fore, and warmed for breakfast. All foods should be com- 
paratively bland in flavor; the use of highly seasoned foods 
and sweets for young children is unpardonable. Rich or 
highly flavored foods are not necessary for a child. To 
permit children to eat such foods and sweets is to encourage 
them to eat increased quantities of food which are likely to 
lack necessary food factors, particularly the vitamines and 
calcium or lime, with a resulting deficiency in growth. The 
natural appetite of a child is sufficient to insure an adequate 
consumption of wholesome food and a healthy child will do 
so provided it has not been allowed to acquire improper 
food habits. A child does not naturally crave rich foods, it 
acquires, or is allowed to acquire, a taste for them. If it is 
taught to eat only wholesome bland foods it will crave 
only such foods. There is plenty of time later in life to 
learn about rich foods. 2 

x See page 269 for the feeding of children through the second year. 

2 This discussion is adapted in part from Diet for the School Child, Bureau of 
Education, U. S. Dept. of Interior and the publications of the Dietetic Bureau, 
Boston, Mass. A bibliography on Child welfare, — Bascom and Mendenhall, 
has been published by the Amer. Med. Assn., 1918; other material may be ob- 
tained from Rose, Feeding the Family; the New York Assoc, for the Improve- 
ment of the Condition of the Poor; Child Health Organization New York; and 
publications of the U. S. Dept. of Agriculture. 



122 FOOD FOR CHILDREN 

Food for Children. Milk and Eggs. — Milk is the most 
important single food in the diet of children and should be 
the chief source of their protein, — it is a protective food — 
i. e., it contains adequate protein, is rich in calcium, phos- 
phorus and has a plentiful supply of fat-soluble vitamine 
and a moderate amount of water-soluble B and the anti- 
scorbutic vitamine; it is deficient only in iron. Children 
between the ages of three to six should receive from i}4 to 
2 pints of milk a day and above these ages at least three 
cups of milk a day. Warm milk is preferable to cold milk. 
When there is an objection to drinking milk as such it should 
be incorporated in other dishes — cocoa, custards, milk soups, 
etc. Dried or evaporated milk may be used when fresh 
milk cannot be obtained, but these milks must be corrected 
for their loss of anti-scorbutic properties. With dried 
skimmed milk, plenty of leafy vegetables or cream or butter 
should be given to supply the fat-soluble vitamine. Eggs 
are included among the protective foods and next to milk 
should be in the dietary of a child. A quart of milk and an 
egg a day will furnish sufficient protein, with that obtained 
in the other foods, for a child up to seven years. Eggs 
should be soft boiled, poached, scrambled or as an omelet, but 
not fried. 

Meat. — The use of meat in the form of beef, mutton, veal, 
fish, etc., is not desirable for young children. The objection 
is not so much to the meat itself as to the fact that it is highly 
flavored. The result is that the child acquires a particular 
liking for meat and unless carefully watched will tend to 
eat it in place of other necessary forms of food ; meat is defi- 
cient in the fat-soluble vitamine and in calcium. Meat 
should be used as flavoring material for cereals, rice, vege- 
tables, soups and stews to stimulate the consumption of 
these foods if necessary, rather than meat as such. The 
allowance of meat should not be more than 60 grams (2 
ounces) for a child between seven to ten years and 90 grams 
(3 ounces) for a child ten to fourteen years old. When meat 
and eggs are scarce or prohibitive cereals and pea or bean 
soup with spinach or other green leafy vegetables should be 
used with milk. 

Cereals, Bread, or Other Grain Products. — Approximately 
one-third of the food required by a child should come from 
the cereals or legumes. Products containing a large pro- 
portion of the whole grain, brown rice, cracked wheat (thor- 
oughly cooked), whole wheat, oatmeal, are preferable to the 
highly milled foods such as polished rice, or white flour, 
since in the process of milling much of the organic material, 



FATS 123 

a part of the protein and most of the vitamines are removed. 
The relative economic value of cereals will be found on page 
141. Cereals should be thoroughly cooked, long slow cooking 
in a double boiler or fireless cooker are desirable. Cereals 
should be served with milk and only a small amount of 
sugar or no sugar at all. The dry partially cooked cereals 
may be used for variety; such foods are both expensive 
and bulky. The flaked products cost approximately two 
to three times as much as the cooked cereal and the puffed 
products six to seven times as much. The best cereals are 
oatmeal, wheatena, pettijohn, cornmeal, hominy, rice, farina 
or cream of wheat. 

Vegetables. — Vegetables are an essential constituent of 
the diet of children, because of the salts and vitamines which 
they contain and because of the indigestible residue which 
tends to prevent constipation. They may be divided into 
two classes, (a) the leafy vegetables which may be considered 
as protective foods in that they supply the fat-soluble, water- 
soluble and anti-scorbutic vitamines, inorganic material and 
bulk to the diet and (b) the roots and tubers which contain 
relatively smaller quantities of each of the articles enum- 
erated under (a) but have in addition more energy produc- 
ing carbohydrates. Potatoes are a very important food and 
should be served practically every day, particularly when 
boiled or cooked in their skins, since in peeling potatoes as 
in milling grains much of the valuable salts and vitamines 
are removed in the process. Rice is another vegetable pro- 
duct which can be used continuously without a distaste 
arising from monotony. For young children vegetables 
should be thoroughly cooked and then macerated and eaten 
as such or made into thick soups. Up to the fifth year, 
potatoes, peas and beans, fresh or dried (in soups) spinach, 
onions, string beans, squash, cauliflower, asparagus, carrots, 
and stewed celery may be used. Above the fifth year all 
vegetables, except cabbage, cucumbers and corn, can be 
eaten. Corn should not be given until the twelfth year. 
In preparing vegetables the water in which they are cooked 
should be served with them or used in soups since a large 
proportion of the salts are removed in the water. 

Fruit. — Fruit should be used each day. If fresh fruit is 
not obtainable cooked, dried or evaporated fruits may be 
used. Fresh fruit should be very ripe. Fruits such as 
oranges, stewed or fresh apples, ripe pears or peaches, stewed 
dried figs, dates, prunes or peaches or ripe or cooked bananas 
may be given. 

Fats. — Fats, particularly butter fat (or cream) are import- 
ant factors in the diet of children because of the fat-soluble 



124 FOOD FOR CHILDREN 

vitamine they carry and the energy which they contain. 
If skimmed milk is used, butter fat should be added to the 
diet or plenty of the leaves of fresh vegetables given to 
furnish the fat-soluble vitamine. Butter substitues may 
be used — the oleomargarines are better than the nut butters 
— if the same correction is made in the diet as for skimmed 
milk. Children should not have cooked fat, except bacon. 

Water. — Give plenty of good water — care must be taken 
that the food is not washed down before it is properly chewed. 

Planning the Meals. 1 — Breakfast. — Breakfast should con- 
sist of milk and bread and butter and when possible in addi- 
tion cereal, fruit and an egg. 

Dinner. — The heaviest meal should be in the middle of 
the day except for children of school age who are compelled 
to hurry back to school immediately after their meal. Din- 
ner should consist of soup, eggs or meat, vegetables, bread 
and butter and dessert. The soup should be made of dried 
peas or beans or fresh or canned vegetables, such as spinach, 
carrots, potato or onions. The addition of rice or barley 
and milk will make a most nutritious dish. If a thick vege- 
table soup is not made another vegetable should be added. 
The desserts should be plain and wholesome, such as fruit, 
cereal pudding, rice, oatmeal or farina with fruit, baked 
Indian pudding, or bread pudding, plain cookies, or cakes, 
and cocoa, fruit custards, junkets, ice cream or ices, sliced 
oranges. 

Supper. — For supper dishes made of milk, eggs, strained 
vegetables (for young children) cereals and fruits are to be 
preferred to meat, whole vegetables, or sweet desserts. For 
example, (a) bread or cereal and milk, potato and fruit or 
eggs; (b) potato, bread and butter, apple sauce and ginger 
bread. 

School Lunches. — When it is not possible for the children 
to come home to a hot dinner at noon and to eat without 
hurrying it is preferable for them to carry their lunch. Such 
a lunch should be both nutritious and appetizing. If pos- 
sible hot cocoa or soup should be served at the school. It 
is essential that the child should have a convenient and 
attractive place in which to eat his lunch and it is desirable 
that a definite time be set aside for a lunch hour, otherwise 
he will be in a hurry to finish and go out to play. A failure 
to make such provision has been found to result in under- 
nourishment even when ample food was supplied. 

Food Habits of Children. — An important factor in the 
proper feeding of children is the establishment of good food 

x See also page 131. 



FOOD HABITS OF CHILDREN 125 

habits. They should be taught, (a) to eat what is given 
them, provided of course that only wholesome food is offered, 

(b) to eat slowly but without delay and in an orderly manner, 

(c) to be regular to their meals, and (d) to have clean hands 
and faces. Children should not be forced to eat when not 
hungry, not be allowed to eat between meals and particu- 
larly not to eat sweets just before meals for such a practice 
will invariably destroy the appetite for the wholesome and 
necessary foods. They should not be allowed to drink tea or 
coffee. The food habits of children are influenced by those 
of the parents. If the parents do not care for the food their 
children should have they must refrain from comment with 
regard to their own likes and dislikes. If a dislike for a 
certain food is expressed by the parents, they cannot expect 
the child to like it. It is on the whole better that the child 
should eat apart from the parents and preferably before the 
regular meal until the third or fourth year or even until the 
sixth year. It is better to modify the habits of the parents 
than to teach the children to like and to demand highly 
flavored foods to the exclusion, or partial exclusion at least, 
of the essential foods a child should have. It is to be re- 
membered that food habits are habits per se and not essen- 
tially natural cravings for particular types of food. Depend 
upon healthy exercise and outdoor living to create an appe- 
tite rather than to stimulate it with special foods or methods 
of cooking. 

The food habits of delicate children have been studied by 
Emerson. 1 It was found that the food habits of children are 
very uniform in that they take the proper amount too much 
or too little food with great regularity. Delicate children 
invariably take too little food. Such children (a) show 
signs of malnutrition in which weight is affected more than 
height, (b) may or may not have retarded mental develop- 
ment, (c) have an unstable nervous system. Physical 
causes modify the food consumption through fatigue, mental 
distress and body defects. To bring about proper nutri- 
tion delicate children should be treated for the physical 
defects, particularly nasal pharyngeal obstructions (ade- 
noids, tonsils, deviated septum, and sinus infections) and 
carious teeth. These children must be kept out of doors 
and sleep out doors if possible. Sweet and rich foods, if the 
children are addicted to them, must be replaced by whole- 
some, simple foods, gradually if necessary, by selecting foods 
as near those of the likes of the child as possible and compat- 

*New York Med. Jour. February 24, 1917. 



126 FASTING 

able with the changes required. Records should be kept 
of the diet to be assured of the value of the changes. Weights 
should be taken to determine the gain or failure to gain. 1 
Periods of rest in bed should be instituted, preferably before 
lunch and before the evening meal or better, after exercise 
and a bath. The meals should be cheerful. Mental dis- 
tress over school work should be reduced as much as pos- 
sible. If addicted to fast eating this fault must be corrected. 
Malnutrition clinics 2 in connection with schools have 
demonstrated the possibilities of correcting the effects of 
malnutrition in children through careful supervision of the 
diet, instruction with regard to food and the arousal of in- 
terest in the individual gain by weekly weighing and plotting 
of the weights. Such clinics were first started by Emerson 
and are now carried out in connection with the work of the 
Bureau of Education, Department of Interior, Child Health 
Organization of New York, and in other cities. 

FASTING. 

The fasting state sometimes prevails in disease as a result 
of obstruction of the alimentary tract or the inability of the 
individual to retain ingested food. Conditions of under- 
nutrition from similar causes are much more common than 
complete fasting. Short fasts are often used in the treat- 
ment of various diseases. A knowledge of the changes in 
the body that result from fasting is of a purely scientific as 
well as practical interest, for it aids in understanding and 
explaining the normal metabolism and certain pathological 
conditions. 

Life is accompanied by various cellular and systemic 
changes which we ordinarily designate as metabolism — pro- 
cesses of synthesis and of decomposition ; oxidation with the 
liberation of carbon dioxide, water, and energy; the forma- 
tion and disintegration of proteins, and the coordination of 
these activities in all parts of the body. Even though food 
no longer be supplied these processes continue. Since the 

1 Emerson believes that any child seven per cent, under weight is to be con- 
sidered as under-nourished. There is some difference of opinion with regard 
to the value of the comparison of body weights with average body weights for 
a given age. The element of race may introduce a factor as great as the one 
indicated. It is wise, however, to consider a child who deviates from the stan- 
ard weights as undernourished until he proves himself to be an exception. The 
taking of weights enables one to follow the rate of growth and to note a failure 
to grow. It is more important that a child should follow the rate of growth 
than it is that he should attain the actual weight indicated in tables of weights. 

2 A bibliography on malnutrition has been compiled by Mrs. Dorothy Reed 
Mendenhal for the Child's Bureau, U. S. Dept. of Labor. 



FASTING 127 

losses sustained in metabolism are then no longer replen- 
ished from ingested material, the more active and essential 
organs make use of similar substances contained in the body. 
Thus we find that the heart, brain, lungs, kidneys, testicles, 
and liver lose a much smaller proportion of their weight 
during fasting than do the muscles and adipose tissue. From 
this we conclude that the former organs which are, in a sense, 
more essential for life obtain the necessary food material 
from the blood which in turn is replenished largely from the 
muscle and adipose tissue. This process of drawing upon 
the tissues for continued activity is not an unusual one. 
There are undoubtedly times between the ingestion of food, 
particularly late during the long interval between the even- 
ing meal and breakfast, when but little food is received from 
the alimentary tract and the body lives at the expense of 
its own stores. 

Not only does the body draw upon its own tissues for the 
material necessary for its activity but it appears to be able to 
utilize these much more economically than it does ingested 
food. In the light of our present knowledge of protein 
metabolism in which, as McCollum has expressed it, the 
processes of repair do not involve the destruction and resyn- 
thesis of entire protein molecules, it seems quite probable 
that one tissue is able to utilize in part the amino-acids 
which have been removed from material in another tissue 
and that the more or less complete disintegration of protein 
in one part of the body serves to supply material for the 
repair of the losses from a number of different tissues in 
other portions of the body. 

The activity of the kidneys, liver, and digestive tract are 
reduced to a minimum in fasting, for they are no longer 
required to take care of an excess of food-stuffs. The kid- 
neys are concerned only with the elimination of the products 
of endogenous metabolism which, as we know, is small in 
comparison with the exogenous metabolism of the average 
individual. The elimination of abnormal urinary constitu- 
ents, as aceto-acetic acids and /3-hydroxybutyric acid or 
bile constituents is sometimes imposed upon the fasting 
kidneys. 

The period of time during which an organism may fast 
depends upon a number of factors. The previous nutritive 
condition has its effect in that the quantity of fat and protein 
which are available determines in part the body reserves. 
The size of the individual affects the rate of metabolism; 
small persons have in general a greater metabolism for the 
body weight than a large person. Age is accompanied by 



128 FASTING 

a varied rate of metabolism ; children metabolize at a greater 
rate than adults and therefore utilize their body stores more 
rapidly than an adult. The external conditions surround- 
ing the body, such as temperature and humidity, may either 
increase or decrease the body activities. The ingestion of 
water tends to lengthen the period an organism may fast 
as compared with a fast without water. Finally, fasting 
experience in a given individual is a modifying factor; as 
the result of repeated fasts the body appears to acquire 
such a resistance that it is better able to withstand the effect 
of each subsequent fast. This appears to be particularly 
true when the organism is permitted to recover from the 
previous fast before being subjected to another. 

Men have fasted for as long as fifty days without apparent 
harm. There are authentic records of a number of thirty- 
day fasts. Benedict 1 has recently reported the result of 
a most careful study of a thirty-one-day fast by a man. 
Animals have been known to fast for much longer periods. 
The longest fast of a warm-blooded animal is that observed 
in a dog which continued for 117 days, after which the ani- 
mal was fed and restored to its original condition and fasted 
again for the second longest fast, 104 days. Cold-blooded 
animals, such as the frog, salamander, etc., have been known 
to fast for much longer periods of time. It is evident, there- 
fore, that the body can obtain from itself sufficient material 
on which to exist for a considerable length of time. Death, 
as the result of fasting in the case of normal individuals, 
is probably due to the failure of some organ or tissue and 
not to the complete utilization of the body stores. Certain 
investigations seem to show that a definite minimum quan- 
tity of nitrogen-containing material is necessary in order 
that life may exist. 

During a fast the general rate of metabolism is lowered. 
Studies of the respiratory changes show that the total quan- 
tity of carbon dioxide excreted per day is lowered, and the 
respiratory quotient falls to a value which indicates the 
oxidation, chiefly, of fat and protein. Protein metabolism 
is also decreased; the daily nitrogen excretion after the first 
few days becomes low and fairly constant. It may fall as 
low as 4 to 6 grams of nitrogen per day. The excretion of 
salts is also diminished. All phases of normal body meta- 
bolism are greatly reduced in fasting. 

1 Benedict has reported a very complete experiment on a man during a thirty- 
one-day fast, Carnegie Institution of Washington, 19 14, Pub. No. 203. The 
data from this fast are published in chart form in Mathew's Physiological Chem- 
istry, New York, 19 15. 



CHAPTER VI 
NORMAL FEEDING AND FOOD ECONOMICS. 

The application of the principles of human nutrition to 
the feeding of the normal individual or to the family group 
is at once involved and difficult. Though the scientist may 
determine and the physician prescribe an ideal dietary, its 
adoption by the individual may be quite impractical, due 
to cost, inconvenience, or lack of market facilities. But 
since foods are interchangeable within wide ranges, a sum- 
mary of the principles of nutrition which underlie the selec- 
tion of food, together with typical menus and a discussion 
of the cost of food may aid in the interpretation and appli- 
cation of these principles. 

Our previous discussion of the various food-stuffs and their 
digestibility has shown that the source of food is of no par- 
ticular importance so long as it possesses all of the necessary 
material and is wholesome, that is, does not contain or yield 
products which are detrimental to the health of the normal 
individual. For example, disregarding for the moment the 
psychological factor, the stomach and intestines can digest a 
cheap cut of meat or fish as thoroughly as an expensive 
steak; American cheese as well as Roquefort cheese; cotton- 
seed oil as well as olive oil. The psychical factor cannot, 
however, be completely ignored for two reasons : 

i. Studies of the secretion of the digestive juices and of 
the rate with which food passes from the stomach indicate 
that appetite, which in its psychological sense is to a large 
extent the reflex of palatability, serves to stimulate an early 
flow of gastric juice and thus facilitate digestion. Once a 
food is digested and absorbed its value to the body is mainly 
a matter of its intrinsic composition. 

2. A diet which contained all of the necessary food fac- 
tors might still prove to be unsatisfactory because of psy- 
chical objections on the part of those who are to eat it. Such 
factors as habit, taste, and custom must be taken into con- 
sideration. The likes and dislikes for food are to a large 
degree governed by the kind and variety of food, method oi 
preparation, etc., which have been observed in the household 
or community in which individuals are reared — a change of 
the usual dietary regimen is accepted with hesitation, which 



130 NORMAL FEEDING AND FOOD ECONOMICS 

can only be overcome by palatability or force of will. If, 
in the latter case, the diet prove to be unsatisfactory, its 
continuance is accomplished with greater difficulty or not at 
all. On the other hand, food well prepared is usually accept- 
able. It is the factor of palatability, based largely upon the 
proper selection and preparation, which determines the suc- 
cess or failure of diets selected because they are economical. 
Palatability is, as we have said before, entirely a relative 
factor, tempered by custom. The diet of the Eskimo, rich 
in fat and very high in protein, is apparently satisfactory to 
him. The peasant's diet of porridge and black bread is 
acceptable, while added white bread or meat constitute 
luxuries. The absence of choice meats, rich sauces or sweets 
from the diet of the well-to-do American is regarded as a 
hardship. A variation of diet outside the range of the 
dietary habits is a matter of acquired taste or necessity. 
When it is necessary or desirable to cause a marked change 
in a diet, careful preparation and serving will do much to 
accomplish that purpose. 

Dtetary Essentials. — A diet which will supply the needs 
of the body must contain : 

(a) Energy-yielding food sufficient in quantity to supply 
the basal energy requirement and to meet the increased need 
resulting from activity. The energy may be derived from 
the oxidation of protein, carbohydrate, or fat, although the 
requirement beyond that obtained from the protein neces- 
sary in other relations, and a minimum amount of fat, is 
satisfied chiefly by carbohydrates. 

(b) Protein, containing the necessary amino-acids, or in 
variety which will yield them in sufficient amount. 

(c) Carbohydrate. 

(d) Lipins (fat), natural and unmodified. 

(e) Mineral matter — salts in quantities and kind sufficient 
to maintain the skeletal structure, equilibrium between the 
fluid portions of the body, and to supply the specialized needs 
of protoplasm in general and of certain organs in particular. 

(/) Substances of unknown chemical nature classed as 
accessory food-stuffs, termed vitamines, found particularly in 
vegetables, coverings of grains and in fatty material. Pre- 
served or highly milled foods are less likely to contain these 
substances than raw or freshly prepared food. 

(g) Bulk or indigestible material to stimulate peristalsis. 

(h) Water. 

The absolute quantities of the various food-stuffs needed 
vary with the size, age and activity of the individual con- 
cerned, and with the external conditions to which he is 
subjected. 



SELECTION OF DIET 131 

The quantitative food requirements of man are as follows: 

Energy. — Forty calories per square meter of body surface 
per hour plus the energy required for general activity; in- 
creased muscular work and external conditions. The daily 
requirement for the average individual at various ages and 
activities may be found on pages 71 and 72. 

Protein. — Equivalent to 10 to 15 per cent, of the total 
calories required per day. For the adult this amounts to 
from 60 to 120 grams per day. 

Carbohydrate and Fat. — The total quantity and the relative 
proportions of these food-stuffs vary with the energy require- 
ments. It has been found that fat and carbohydrate may 
be used in the diet in the proportion of 7 to 2 without ap- 
parent marked disturbance in metabolism. The average 
diet, however, contains a preponderance of carbohydrate. 
The average fat intake is from 25 to 75 grams per day. 

Mineral Matter. — With the exception of phosphorus, cal- 
cium and iron, little is known in regard to quantitative 
requirements. The quantities of inorganic constituents 
which are required daily by the average individual have 
been estimated as follows: 

Phosphoric acid (P2O5) 3.3 

Calcium oxide (CaO) 1.0 

Iron (Fe) 0.015 

Accessory Foods and Bulk. — The average mixed diet con- 
tains sufficient quantities of these substances. For further 
discussion see pp. 102 and 238. 

Planning Meals. — The object to be attained in planning 
meals is to furnish the necessary food elements in their 
proper proportions and in an attractive manner. To accom- 
plish this end not only the food factors must be considered 
but the types of food acceptable to the individuals who are 
to eat which will supply these factors. The following typ- 
ical menus prepared by Miss Rose as suggestions in plan- 
ning the diet of a family of moderate means, including 
children above two years of age, may be regarded as illus- 
trations of properly selected diets. Certain foods, as pan- 
cakes and sausages, are included to increase the variety for 
adults who are accustomed to a more varied diet than chil- 
dren. 

Menu I. 

Breakfast: 
Wheaten grits with cream or whole For all members of the family. 

milk. 
Oranges. For all members of the family except 

very little children, to whom orange 
juice may be given between meals. 



132 NORMAL FEEDING AND FOOD ECONOMICS 



Bread and butter. 
Sausages. 
Pancakes. 
Coffee. 

Dinner: 
Soup. 
Roast mutton. 

Baked potatoes. 
Spinach. 

Bread and butter. 
Milk to drink. 
Apple pie. 
Apple sauce. 
(An egg for children 
plan.) 

Supper: 
Milk toast. 
Scrambled eggs. 
Bread and butter. 
Peach sauce > 
Cookies. 1 



For all members of the family. 
For adults. 
For adults. 
For adults. 



For adults and older children. 

For all members of the family except 

children under seven years of age. 
For all members of the family. 
For all members of the family. 
For all members of the family. 
Especially for children. 
For adults. 
For children, 
under seven years of age may be included in the above meal 



For all members of the family. 
For adults. 

For all members of the family. 
For all members of the family except 
very small children. 



Menu II. 



Breakfast: 
Rolled oats with cream or whole milk. 
Stewed prunes. 
Bread and butter. 
Milk to drink. 
Eggs: 

Poached. 

Fried. 
Coffee. 

Dinner: 
Soup. 
Pot roast. 
Boiled potatoes. 
Creamed onions. 
Bread and butter. 
Milk to drink. 
Custard pie. 
Baked custard. 

Supper: 
Scalloped rice with cheese. 
Plain boiled rice with cream or whole 

milk. 
Bread and butter. 
Milk to drink. 

Fruit sauce or baked apples i 
Molasses cookies. i 



For all members of the family. 
For all members of the family. 
For all members of the family. 
For all members of the family. 

For children. 
For adults. 
For adults. 



For adults and older children. 
For adults and older children. 
For all members of the family. 
For all members of the family. 
For all members of the family. 
Especially for children. 
For adults. 
For children. • 

For adults and older children. 

For younger children. 

For all members of the family. 

Especially for children. 

For all members of the family. 



Menu III. 



Breakfast: 
Cornmeal mush with cream or whole 

milk. 
Stewed fruit. 



Bread and butter. 
Milk to drink. 
Bacon. 



For all members of the family. 

For all members of the family except 

very little children; to be given to 

children between meals. 
For all members of the family. 
Especially for children. 
Especially for adults. 



SELECTION OF DIET 133 

Waffles. For adults. 

Coffee. For adults. 

Dinner: 

Baked Hamburger steak. For all members of the family except 

children under seven years of age. 

Creamed potatoes. For all members of the family. 

Mashed potatoes. For small children. 

Buttered carrots. For all members of the family. 

Bread and butter. For all members of the family. 

Milk to drink. Especially for children. 

Steamed suet pudding. For adults. 

Baked apples. For children. 

Supper: 

Cream of bean soup. For all members of the family. 

Bread and butter. For all members of the family. 

Prune sauce. For all members of the family. 

Sponge cake. For all members of the family. 

The table on page 134 suggests the fuel value or calories for 
the meals of a day apportioned among the various types of 
foods suitable for persons of different ages, under normal 
conditions. 

In this table a distinction is made between the starch-rich 
vegetables which supply considerable quantities of energy 
in the form of carbohydrates and the green vegetables which 
are particularly valuable for the bulk which they give to the 
contents in the alimentary tract, because of the indigestible 
cellulose contained, and for the salts and accessory substances 
in which they are particularly rich. The dishes classed as 
meat may often be combined with another class of food such 
as starch-rich foods or milk, as for example meat-pie, creamed 
beef, or oyster stew. 

It must again be emphasized that the physician who pre- 
scribes as well as the housekeeper who plans meals for a fam- 
ily must be sufficiently familiar with the composition of most 
of the common foods to be able to class them as valuable 
sources of protein, fat, carbohydrate, or salts. If they do not 
possess this knowledge one type of food may exceed its most 
satisfactory proportion in the diet. It is necessary, too, that 
correct dietary habits be established by children. Prefer- 
ence for a particular food must not lead to the habit of "mak- 
ing a meal" of it. Likes and dislikes for food are largely a 
matter of habit, and the importance of an early establish- 
ment of good food habits cannot be overestimated. While 
it is not necessary that each meal or the combined meals of 
one day be complete in meeting the requirements of an in- 
dividual, such a balance should be approximated and satis- 
fied at least within the course of a few days. The following 
menus, and the table giving the relative proportion of pro- 
tein, fat and carbohydrate in them, will serve to illustrate 



134 NORMAL FEEDING AND FOOD ECONOMICS 



O w 

M ^ 



£ w 

w ~ 
fa 





» 


o 


O O O O 


o 


ed 

cu O 


o o o o o 




OOO 









■3 


o 


O O uo O 


o 


4-> o 


iO o o o o 




CO O O 







*o 


<u 


00 


M « M CM 


CM 


s T 


HN m (MO) 




M M CM 




CM 


oj 


>> 




III 1 


1 


III II 








1 -* 
O 


< 


o 


o 
o 


to o io 


o 


*£ 


O O to o o 




10 




n o n o 


o 


O O N o o 




O NO 




O 




o 


"■> 






Tt- 














C m 


o 
o 


§-§ .88 

II CM H 


o 


,— , 


o o o o o 










O 






o 




O O iO o o 










IO 




ro 


CM 




• CO n n CO CM 


co 


• CO CM 








T3 L. 


O 


s>8 : sa 


1 
o 




• O O iO o o 





• 1 1 

• O O 




I '■ 




o 


o 




O <0 (M O IO 





O IO 




O 




<? 


M 


M 




CM ii m ii 


1-1 


M H 




11 


w 


o 


o o o 


o 




o o o 





OOO 








b 


o 

o 


O O O iO 


IO 




IO O iO o o 


10 


OOO 








<u 


MM • M N 


HH 




■ NH n H O 


h-l M 


CO 11 CM 








>> 


o 


O iO • o o 


o 




• O iO O iO o 





OOO 








H 


o 


ION IO IO 


o 




IO N n N IO 


10 


10 






2 
2 
u 


00 


M 




1-1 




1-1 


1—1 


CM M 






<a 


o 


o o o 


o 


IO IO 


o o o 










O 


u 


o 


o o o o 


o 


n cm 


IO O iO o o 


10 







O 






MM • M IO 


cm 


M M 


. t^ M M M CM 


M H 


• • CM 




• CO 




>> 


o 


II -II 
O O 'O iO 


o 


1 1 
»o IO 


• o o io o 6 


1 1 




'. '. 




• O 




t^. 


o 


IO IO IO CM 


iO 


CM N 


IO iO IO o 


10 







»o 




IO 




M 


1-1 


M 


1-1 


1-1 




M 


o5 


o 
o 


o 


o 




o o o 










'co 




4/ 


o io io 


N 


IO 


O O iO iO o 





10 




O 




ION • M • 


CM 


O N 


CM 00 • ii ii CM 


• CM 


■ M 




• co 




>> 

r 


o 


IO o • o • 


o 


£r 


II -III 

O O • iO iO o 


• 


^ • • 10 

M 




:-i 




o 


CM IO IO 


IO 


IO 


iovo r^ o 


»o 









ro 


M 




1-1 




m" 


1-1 




CM 






o 


o o o o 


o 




Jz o o o o o o 




S 
g 

£ rf CM rh CM 

R 1 1 1 1 

J 






6 
> 


o 

CO 


O iO O iO 


o 




h, o iO iO iO o o 

m 1 n CO CM CO CM ^h 








J M M CM H • 


IO 










+3 


1 

o 


s o o o o • 

W io io O iO 


o 




Q iO o o o o o 








< 


o 

<N 


>o 




at CM O iO O >0 O 




10 




c 

E 
o 




£ M 


0) 




q CM n CM CM 




K CM n CM h 

O 










o 






M 










>, 


o 


>z OOO 

5 o o o 


o 




<J o o o o o o 





M O O O 




IO 




o 


o 




HOOiOOOO 





<J 10 10 10 




N 




a) 


r<5 


£ o 7 cm 7 


CM 




DAY M 

25-1 

150-3 

1 00- 1 
100-2 

75-2 
200-3 


CM • 


w ? 7 7 




n 




a 


« O III 

y io io co 


o 




1 
O • 


s 




: 




-a 


O 


o 




iO 


£2 2 




10 




ti 


00 


1-1 








1-1 






o 


o o o o 






O OOO 




^ O O N 








o3 

> 


o 


o o o o 






2 O OOO 

S • CO O CM ^ "3- O 




W O O IO 








• CO CO -^t- CO 


o o 






> ^t- rJ" iO 




• 




CJ 


o 


• o o o o 


o o 




• 1 10 1 1 1 

• O n O O O CM 




Will 

R 




• 

CM • 




< 


o 

C3 


iO O O iO 






10 00 10 




OOO 






2 




M CM CO 1-1 






1 n CM CM 




CM CM CO 






>. 


O 
O 


o o o 


o o 




00000 




OOO 




O 




J3 


o o o 


iO o 




10 10 10 




OOO 




iO 




ctf 


(N 


O h N fl O 


CM i-i 




r^ co m cm n co 




CM CM 'st- 










o 


O 1 1 1 o 

M O O O 1 


o o 




1 1 1 1 1 1 
000000 




OOO 




O ^ 




•a 


o 


iO O O 


O iO 


IO 10 




OOO 




O 




w 


<M 


M M 


M 




M M M (\J 




HH« 




1-1 








i 




-^ 


1 • 






O 






-J 

c 

<D 

5 
a; 
i-. 

"3 

c 

s 

'3 
•a 




Id 

a; 

cu 
o 

o 




u 

a 
3 


g salads) 
or cocoa 




CO 

-5 


CD 

CU 

c 
u 

O 


'Sm 






hot cakes 
nargarine 
. (for coffee 




^ — 


c <u 




0) 


V^-i 








o 

CO 

6 

CD 


^egg for children) 
vegetables (includi 

t . . . . . 

and sugar for coffe 
ts) .... 




CO 

<v 

. . 

O 
+-> 

Rj 


ed 

OJO 

3 
en 

3 

cd 


.43 

3" 

2 




3 

o 
H 




it . . 
el . . 
at or eggs 
ad, rolls or 
ter or oleoi 
k or cream 


to 


3,0 

'•§•§ 

O Cd 


a 




light me 
or rolls 
t . . 


M 
1 

Q 


' IS 

• >- 



cd"*- 








"3 w. 


"^TJ 


3 8 £ g OJ »-^ 




. In h 

-T3 CU QJ 


6 


cd 








t3 cdJ4 cd 


tl — 


O-rt tnf 


ed 


O 4) 








2 &£ £ 3g 


C/2 




3 2 




CU 

u 


a; 
U 



.X) 

co cd 

cu +- 1 

.5 cu 

J- be 

^O cu 

"cd > 



I be 
•3 cd 



O > 



4) 1 



+3 ^ 






C10 



SELECTION OF DIET 135 

the possibility that even in an apparently well selected diet, 
some one foodstuff may predominate. 

Examples of one-sided diets, predominantly protein, fat, 
or carbohydrate and an analysis of their composition have 
been given by Langworthy. l 

Menus with Protein Predominating. 

Breakfast: Cereal cooked in milk, chicken hash with egg, popovers, butter, 
and milk as a beverage. 

Dinner: Dried-bean puree, halibut steak, potatoes scalloped in milk, tomatoes 
stuffed with chopped beef, bread and butter, and frozen custard with nut cookies. 

Lunch or Supper: Baked beans, nut bread and butter, old-fashioned rice 
pudding, and a glass of milk. 

Menus with a Large Proportion of Fat 

Breakfast: Oatmeal with cream, sausage, and corn bread and butter. 

Dinner: Cream of tomato soup, mutton chop with creamed potatoes, greens 
cooked with bacon or pork, bread and suet pudding with hard sauce. 

Lunch or Supper: Creamed salmon, lettuce with oil dressing, tea biscuits and 
butter, pumpkin pie and a cup of chocolate. 

Menus with Carbohydrate Predominating. 

Breakfast: An orange followed by corn cakes with maple syrup, and bread or 
toast and butter. 

Dinner: Meat pie and baked potato, green peas, bread and butter, and cot- 
tage pudding with chocolate sauce. 

Lunch or Supper: Rice croquettes with jelly, rye bread and butter, baked 
apples, and sugar cookies. 

The Composition of the Nutrients and the Energy Supplied by 
the Above Menus Used for Illustration. 





Weight of 






Carbo- 






edible food 


Protein, 


Fat, 


hydrates, 


Fuel value 




served, gm. 


gm. 


gm. 


gm. 


Calories. 


Protein meals: 












Breakfast 


• 471 


36 


50 


54 


810 


Dinner 


772 


58 


64 


120 


1288 


Lunch or supper . 


• 639 


33 


38 


105 


894 


Total . . . 


. 1882 


127 


152 


279 


2992 


Fatty meals: 












Breakfast 


• 353 


24 


69 


58 


949 


Dinner 


. 617 


33 


88 


108 


1356 


Lunch or supper . 


621 


29 


83 


98 


1259 


Total . . . 


• 1591 


86 


240 


264 


3564 


Carbohydrate meals: 












Breakfast . 


• 509 


15 


32 


168 


1020 


Dinner 


• 529 


40 


33 


133 


989 


Lunch or supper . 


• 376 


14 


27 


127 


807 



Total .... 1414 69 92 428 2816 

Scientific Monthly, 1916, ii, 294. 



136 NORMAL FEEDING AND FOOD ECONOMICS 

Cost of Food. — No discussion of the question of normal 
nutrition is complete without a consideration of the cost 
of food. To those persons into whose hands falls the plan- 
ning of a dietary for the normal family, the problem is not 
entirely one of furnishing a diet in which correct relative 
amounts of protein, fat, carbohydrate, mineral constituents 
as well as accessory substances are provided. Their prob- 
lem is, in addition, to select such a diet which can be supplied 
at a cost not exceeding a fair proportion of the income of 
the family. 

The following table shows the proportion of the income to 
be spent for food, as observed by the Bureau of Labor 1 
for 92 industrial centers in the United States.. 



Proportion of Income Spent for Food. 



Income 


Percentage for 


Total for food 


Average number 


Amount 


per c 


per year. 


food per year. 


per year. 


in family. 


per person 


Under $900 . 


44 


$37 1 


4-3 


$0.24 


900-1200 . 


42 


456 


4-5 




28 


1200-1500 . 


39 


515 


4-7 




30 


1500-1800 . 


37 


572 


5.o 




31 


1800-2100 . 


36 


626 


5-2 




33 


2100-2500 . 


35 


711 


5-7 




34 


Over 2500 . 


35 


860 


6-4 




33 



From considerations of the energy value of the food pur- 
chased by the families represented in the accompanying 
data it was found that, in general, for any community a 
higher energy content was purchased with an increase in 
income. Comparisons of income groups in different com- 
munities showed that a low income group in some cases 
purchased for a smaller expenditure food value equal to that 
of a higher income group of another community. The 
underlying causes of such variations are rather ill-defined 
but are related, apparently, to the congestion and size of 
the city and to the geographical location as well as to the 
food habits. Comparisons of families having the same in- 
come but of varying size showed a decreasing food value 
purchased per member with an increase in the size of the 
family. 

Fortunately there is not a direct relation between the cost 
of food and its nutritive value. An inexpensive diet, so far 
as the needs of the body are concerned, may be as satis- 
factory as an expensive diet. Too often, however, lack of 
knowledge and training in the selection and preparation 
adds unduly to the cost of food, especially among the poorer 
classes who can least afford unwise expenditures. 

1 Monthly Labor Review, 1919, ix. 



COST OF FOOD 137 

The physician is particularly interested in prescribing a 
diet which contains the special nutrients needed by his 
patient at a cost within the means of the family. Too often 
diet lists are not flexible, although good ^results might be 
obtained by the use of other and less expensive equivalents. 
The work of Hess in studying the effect of extract of orange 
peel and potato water as a preventative of scurvy in infants 
has shown possibilities in this direction. 

It would seem, then, incumbent upon the purchaser of the 
family food supply to familiarize herself with the composi- 
tion of the common foods and at least roughly with the cost 
in relation to their total food values. The tables on page 
138 show foods typically high and low in cost in proportion 
to their food values. 1 

It is readily seen from such tables that but few foods 
were obtainable at a cost of less than one-third of a cent per 
100 calories and that few of the foods in the first table are 
perishable or difficult of transportation. Fresh fruits and 
vegetables, fresh meat, milk and eggs all cost one cent or 
more per 100 calories. 

Lusk and Murlin have suggested that the labels on food 
containers should indicate the energy value of the contents 
and the percentage of protein contained. The nature of 
the proteins would be indicated by letters — complete pro- 
teins, such as animal proteins would be designated as pro- 
teins, of " Grade A," while incomplete proteins, such as 
gelatin, would be "Grade D." Mixtures of complete pro- 
teins "A" and incomplete proteins "D" are in what would 
be marked "Grade B," while foods containing a large pro- 
portion of incomplete protein, as corn, would belong to 
"Grade C." The label might read: "This can contains 
X calories of which Y per cent, are in protein of "Grade C." 

An illustration of the variation in the cost of a menu 
while maintaining the calorie content of the diet constant is 
found in the summary of menus on page 139 prepared by Mrs. 
Rose for prices in 191 6. The reduction is accompanied by 
a reduction in protein calories. 

The factors which influence the cost of various foods are, 
as we have noted before, in many cases independent of their 
food values, but depend upon quite external conditions, such 
as source, perishability, supply and demand, proportion of 
waste, etc. This is particularly true of our most expensive 
food-stuffs. An understanding of the relative cost of food 
necessitates, therefore, a knowledge of the factors which 
underlie the relation between food value and cost. 

Sevier: Planning of Meals, Univ. of 111. Bull., 1914, xi, No. 30. 



138 NORMAL FEEDING AND FOOD ECONOMICS 

Foods Low in Cost in Proportion to Their Total Food Value. 1 2 















Grams of 




Cost per 








protein in 




pound 


Calories 


Ounces in 


Cost of 100 


100-Calorie 


Kind of food. 


(Jan., 1913). 


per pound. 


100 Calories. 


Calories. 


portion. 


Cornmeal . 


$0,025 


1655 


96 


$0.0015 


2-59 


Wheat flour 


03 


1655 




96 


.0018 


3-87 


Oatmeal . 


•45 


i860 




86 


.OO24 


4.20 


Sugar, granulated . 


.06 


i860 




86 


.OO32 


O.OO 


Beef heart . 


•05 


1320 


I 


21 


.OO37 


6.4O 


Beans, navy dried . 


.062 


1605 




99 


.OO38 


6.82 


Cross ribs of beef . 


.08 


1765 




906 


.0040 


5.10 


Lard, best leaf . 


.18 


4220 




37 


.0040 


O.OO 


Potatoes at $i bushel 


.016 


385 


4 


15 


.0041 


2.64 


Peanuts, shelled 


. 12 


2560 




62 


.OO46 


4.69 


White bread 


.07 


1225 


1 


30 


.0057 


3.60 


Brisket of beef . 


.07 


1 165 


1 


37 


.0060 


4.90 


Rice 


. 10 


1630 




98 


.0061 


2.28 


Oleomargarine . 


.22 


3525 




45 


.0062 


O.OO 


Flank of mutton 


.125 


1900 




85 


.OO65 


3-75 


Bacon . . . 


.20 


3030 




52 


.0066 


1.68 


Dates .... 


. 10 


1450 


1 


10 


.0068 


0.61 


Corned beef 


.14 


1990 




80 


.0070 


5.22 


Skim milk at $0.10 gal 


.0125 


170 


9 


40 


.0073 


9.26 


Whole milk at $0.10 qt 


.046 


314 


5 


09 


.OIOI 


4.76 


Salt mackerel . 


.10 


1 155 


1 


38 


.OO86 


5-6 5 


Butter .... 


•36 


3605 




44 


.OO99 


4-54 


Cheese, cheddar 


.22 


2145 




74 


.0120 


6.50 


Walnut meats . 


•45 


3300 




48 


.0139 


2.61 


Round steak 


•15 


895 


1 


70 


.OI67 


12.62 


Foods High in Cc 


>st in Proportion to 


Their Total Food Value. 1 2 












Grams of 




Cost per 








protein in 




pound 


Calories 


Ounces in 


Cost of 100 


100-Calorie 


Kind of food. 


(Jan., 1913). 


per pound. 


100 Calories. 


Calories. 


portion. 


Mushrooms 


$0.65 


210 


7-6 


$0,309 


$7-54 


Lettuce .... 


•15 


75 


21.3 


.200 


5-44 


Lobster, fresh . 


•25 


140 


11. 4 


.178 


19.07 


Black bass . 


30 


205 


7-8 


. 146 


20.56 


Chicken, broiler 


•30 


295 


5-4 


. 101 


19.6 


Sweetbreads 


.80 


825 


1-93 


•095 


905 


Oysters .... 


.20 


230 


6.9 


.087 


12.27 


Cauliflower . 


. 12 


140 


11. 4 


.085 


8.16 


Rhubarb 


•05 


65 


24.6 


.077 


2.79 


Celery .... 


•05 


70 


22.8 


.070 


4.08 


White fish . . . 


.20 


325 


4-9 


.06l 


14.72 


Oranges .... 


. 10 


170 


9-4 


.058 


1.6 


Tenderloin of beef . 


.60 


1330 


1.2 


•045 


5-51 


Porterhouse steak . 


•30 


IIIO 


1.44 


.027 


7-8 


Sirloin steak 


.25 


985 


1.62 


O25 


7.58 


Roquefort cheese 


•45 


1700 


•94 


.024 


6.02 


Leg lamb, medium fat 


.18 


870 


1.80 


.020 


8. 11 


Rib roast, medium fat 


.20 


1 155 




1-38 


.017 


5-52 



1 Based on Bulletin 28, "Composition of American Food Materials. " Office of 
Experiment Stations, U. S. Dept. of Agriculture. 

2 The prices given apply to the year 1913, and are for comparative purposes 
only. Present prices of food are abnormal (19 19). According to statistics 
published by the Bureau of Labor, Monthly Labor Review, Vol. 8, May 19 19, 
the increase in cost of food using 1913 prices as a basis, or 100, is as follows; 
1913, 100; 1914, 102; 1915, 101; 1916, 114; 1917, 146; 1918, 168; 1919, 234, 



COST OF FOOD 



139 



Typical Menus of Varying Cost of a Family of Eight. 1 

Requirements of family (man, woman, baby one year, boy three years, two girls six and nine 
years, boy twelve years, grandmother ninety years). Protein Calories, 1424-206 1. Total Cal- 
ories, 14,252. 

Menu I. Menu II. Menu III. Menu IV. 

1K-2 c. per 100 Cal. 1X-1K c. per 100 Cal. %-\ c. per 100 Cal. -H c. per 100 Cal. 



Breakfast. 



Oranges. 

Wheatena with top 

milk. 
Puffy omelet with 

bacon. 

Toast, coffee, milk. 



Creamed chicken on 

toast. 
Baked bananas. 
Boston brown bread. 
Rice pudding. 
Tea, milk. 



Consomme. 
Baked halibut, egg 

sauce. 
Potatoes on half shell. 
String beans, buttered. 
Bread and butter. 



Oranges (small). 

Wheatena with top 
milk. 



Toast, coffee, milk. 



Bananas (prune pulp 
for two youngest). 

Wheatena with top 
milk. 



Toast, coffee, milk, 
cereal coffee. 



Mid-day Meal. 
Creamed dried beef on Macaroni and cheese, 
toast. 



Baked bananas. 
Boston brown bread. 
Rice pudding. 
Tea, milk. 



Stewed apricots. 
Boston brown bread. 
Oatmeal cookies. 
Tea, milk. 



Evening Meal. 



Baked halibut, white 

sauce. 
Potatoes on half shell. 
String beans, buttered. 
Bread and butter. 



Creamed salt cod. 

Baked potatoes. 
Boiled onions. 
Bread and butter. 



Tomato salad, French Cold slaw. 

dressing. 

Apple snow with boiled Chocolate blanc mange Rice pudding, cream 

custard. cream and sugar. and sugar. 

Lady fingers. Plain cookies. 



Protein Calories, 2202. Protein Calories, 2106. 
Total Calories, 14,410. Total Calories, 14,414. 



Protein Calories, 1791. 
Total Calories, 14,330. 



Stewed dried apples. 

Cornmeal mush with 
milk and sugar. 

Bread, pork fat; sau- 
sage for father and 
mother. 

Cereal coffee for older 
children and adults. 

Milk. 

Baked samp, with 

cheese. 
Stewed raisins. 
Oleomargarine. 
Brown bread. 
Oatmeal wafers. 
Tea for adults, cocoa 

for children. 



Beef stew with vege- 
tables. 



Bread and oleomargar- 
ine. 



Date pudding with 
liquid sauce. 

Protein Calories, 1526. 
Total Calories, 14,299. 



Our food is derived from two sources, animal and vege- 
table. Animal foods are particularly valuable as a source of 
protein and fat; they contain little carbohydrate. Vegetable 
foods are our chief source of carbohydrate, and they are to 
a less extent a source of protein. Both animal and vege- 
table food supply inorganic salts and accessory substances; 
green vegetables are valuable largely because of these 
materials. 

Food derived from animals fed with cultivated fodder is 
much more expensive than the vegetable foods used in its 
production. This is true because animal food is developed 
largely at the expense of vegetable food; a process the effi- 
ciency of which is comparatively low. Furthermore, ani- 
mals must often be kept for a period of years for their proper 
development, during which time they must be carefully 
tended; and they are also subject to disease with the possi- 
bility of loss by death. Flesh foods obtained from wild 
animals, such as fish and game, might be relatively cheaper 
because the only factors of cost involved are those of catch - 

iRose: Feeding the Family, New York, 19 16. 



140 NORMAL FEEDING AND FOOD ECONOMICS 

ing or killing the animals, preserving and sending them to 
the market. Although game may be procured cheaply, it 
is expensive to the average individual because of its scarcity. 
Similarly, fish is expensive in certain parts of the country 
because of the cost of transportation and storage. 

The perishability of fresh animal food also tends to make it 
expensive. With the exception of the isolated fat products, 
meat decomposes rapidly at ordinary temperatures. It must 
be preserved therefore by processes which are comparatively 
expensive, such as refrigeration. Furthermore, care must be 
exercised in handling it to prevent contamination. In addi- 
tion there is a certain loss by deterioration when such food 
passes through the hands of the retailer, and this loss must 
be made good in the price charged for the remainder. 

Various methods of preservation of animal food in com- 
mon use operate to lower its cost to the consumer. Cold 
storage or refrigeration is a comparatively expensive process 
of preservation and tends to increase the cost of flesh foods; 
in spite of this it is a means of actually reducing the cost 
of such foods because it permits the slaughter of animals in 
large quantities and their transportation to the consumer 
with a relatively low loss by deterioration. Refrigeration 
permits the storage of other perishable animal food, such 
as eggs, in seasons in which they are plentiful. The net 
result of such preservation is a gain to the consumer, for 
while it tends to increase the cost when the foods are in 
season, it brings the cost of the same food out of season 
below what it would be were there no refrigeration. 

Other methods of preservation, such as drying (beef and 
fish), smoking, pickling, and canning, which do not require 
extensive refrigeration and which are performed where the 
supply is plentiful, also tend to lower the cost of animal 
foods. Processes which involve special manipulation of the 
food, such as the preparation of cheese and the extraction 
of fat, are also means of lowering the cost of animal foods. 

Plant foods are cheaper sources of food material than 
animal foods. They are used directly and the only loss to 
the body is that which results from a failure to absorb or to 
utilize them completely. Their cultivation is comparatively 
simple, and they mature in one season. Artificial preservation 
is not so essential and, when practised, is comparatively 
cheaper than the preservation of more perishable foods in their 
natural state. Plant foods, such as carrots, potatoes and 
apples when ripe can be stored for some months with little 
deterioration; with a slightly increased expense for cold 
storage they may be kept for even longer periods. Foods 



COST OF FOOD 



141 



which would decay at ordinary temperatures, such as oranges, 
can be preserved in cold storage. Many plant foods are 
preserved in the dry state. Some become relatively dry 
before they are gathered, such as the legumes — beans and 
peas — and the grains — corn, oats, and wheat; while other 
foods used extensively in the fresh state — prunes, apples, 
apricots — are dried under special, artificial conditions. Mill- 
ing of cereals and grains helps to extend the period of preser- 
vation without deterioration; this is particularly true of 
fat-rich grains, such as corn. Some plant foods, such as 
corn, peas, and tomatoes may also be preserved in the fresh, 
water-rich state by canning. This is done at times when 
they are plentiful and in districts in which they are pro- 
duced, thus furnishing a supply of these foods at reason- 
able prices during seasons in which they would otherwise 
be unobtainable. 



Relative Economy of Foods. 
(Dietetic Bureau, Boston, Mass.). 



I. Very Economical. 



Oatmeal up to 16 cts. per lb. 
Barley up to 10 cts. per lb. 
Cornmeal up to 9 cts. per lb. 
Hominy up to 8 cts. per lb. 
Rice 



Prunes up to 16 cts. per lb. 
Raisins up to 16 cts. per lb. 
Dates up to 17 cts. per lb. 
Dried apples ) up to 
Dried peaches > 14 cts. 
Dried apricots ) per lb. 
Fresh apples up to 2 cts. per 
lb. 



Dried beans ) at any ordinary 
Dried peas > price, even 25 

j cts. per lb. 
Spinach up to 10 cts. per lb. 
Potatoes up to 5 cts. per lb. 
Cabbage up to 5 cts. per lb. 
Onions up to 4 cts. per lb. 
Cauliflower at 8 cts. per lb. 

(provided outside leaves are 

used in some way). 
Beets up to 4 cts. per lb. 
Carrots up to 4K cts. per lb. 
Turnips up to 4 cts. 



2. Economical. 
Cereals. 
At any reasonable price. 
At any reasonable price. 
At any reasonable price. 
At any reasonable price. 
Up to 15 cts. per lb. 
Pettijohn at any reasonable 

price. 
Shredded Wheat up to 15 cts. 

per box. 
Cream Wheat / up to 25 cts. 
Farina } for i$i lb. box. 

Fruit. 
Up to 23 cts. per lb. 
Up to 23 cts. per lb. 
Up to 25 cts. per lb. 

Up to 20 cts. per lb. 

Up to 3 cts. per lb. 
Bananas up to 30 cts. per doz. 
Grapes up to 8 cts. per lb. 
An occasional orange (once a 

week for the baby) at 50 cts. 

per dozen. 

Vegetables. 



Up to 16 cts. per lb. 
Up to 8 cts. per lb. 
Up to 7 cts. per lb. 
Up to 6 cts. per lb. 
Up to 13 cts. per lb. 

Up to 6 cts. per lb. 
Up to 7 cts. per lb. 
Up to 6 cts. per lb. 

String beans up to 10 cts. per 

lb. 
Fresh peas and beans up to 

10 cts. per lb. 
Squash up to 3 cts. per lb. 
Tomatoes at 5 cts. per lb. 



3. Expensive. 



Corn Flakes at any price. 
Puffed Wheat at any price. 
Puffed Rice at any price. 
Post Toasties at any price. 
Krumbles at any price. 



Fruit in column 2 above the 

prices named 
Plums over 1 cent each. 
Peaches over 1 cent each. 
Pears over 1 cent each. 



Any of the foods above the 
price named in column 2 

Canned peas above 15 cts. 

per can. 
Canned corn above 17 cts. 

per can. 
Any other canned vegetable 

purchased at the store. 

Celery above 11 cts. per 

bunch (3 roots). 
Asparagus above 10 cts. per 

lb. 
Lettuce above 5 cts. a head . 



142 NORMAL FEEDING AND FOOD ECONOMICS 

The table on page 141 gives the relative economy of vege- 
table foods. It is of value in determining the wisest ex- 
penditure of money for these articles. 

Many foods which appear cheap, i. e., are sold at a low 
cost per pound, are in reality expensive on account of the 
large amount of waste in skin, bone, seeds, etc. ; for example, 
a chicken weighing 4.65 lbs., costing 40 cents per lb. alive, 
weighed 4.09 lbs. dressed, and yielded but_i.ii lbs. cooked 
meat, which brought the cost up to $1.69 per pound. 
Small prunes prove more expensive than larger ones costing 
5 to 8 cents per lb. more, owing to the greater waste in skin 
and seeds of the smaller prunes. 

The cost of food is also influenced by supply and demand. 
In the case of meat, the demand for special cuts of which 
there are but a few in each carcass, such as tenderloin steaks 
and sweetbreads, results in prices which are out of proportion 
to the food value of these cuts. These unnatural prices 
react favorably upon the less desirable cuts, for they are 



Cost of Meat Required to Furnish One Pound of Protein and 
1000 Calories from Wholesale Cuts at Market Prices. 1 ' 2 



Wholesale cuts. 



Fore shank 

Hind shank 

Neck 

Flank 

Plate 

Clod 

Chuck 

Rump 

Round 

Rib . 

Loin . 



Retail 

price per 

pound, 

cents. 

5 

5 

6 

8 

8 

10 
11 
12 

15 

18 
22 



Boneless 
meat in 
the cut, 
per cent. 

59 -56 
48.84 
84-31 
99-44 
91.23 

95-18 
87.99 

79-85 
90.39 
85.56 
90.23 



Cost of pound 

boneless 

meat in cut, 

cents. 

8.4 
I0.2 

7-i 

8.0 

8-7 
10.5 
12.5 
15.0 
16.6 
21.0 
24.4 



Cost of 
pound 
protein in 
cut, cents. 

50 
63 
46 

85 
82 

63 

84 
II 9 
1 01 
171 



Cost of 
1000 Cal- 
ories in 
cut, cents. 

7 
9 
5 
3 
4 
10 

9 

8 

15 
11 

14 



Relative Fuel Values of the Boneless Meat of the Wholesale Cuts. 1>2 



Calories furnished by ioo grams of 

boneless meat. 
Fat x 9. Protein x 4. Total. 

554 
483 
419 

405 
396 
313 
303 
257 
253 
250 

235 



Flank 


• 514-4 


40 


5 


Plate 


• 437-1 


46 





Rib . 


■ 365-6 


54 


1 


Rump 


- 350.5 


55 


3 


Loin . 


• 339-4 


57 


4 


Chuck 


. 247.9 


65 


8 


Neck 


• 235 • 1 


67 


9 


Hind sha 


nk . 186.9 


7i 





Fore shar 


ik . 179.8 


73 


9 


Round 


■ 176.9 


73 


6 


Clod 


. 161. 6 


73 


5 



Percentage distribu- 
tion of Calories. 
In fat. In protein. 

3 
5 
9 
6 

5 
o 

4 

5 
1 

4 

3 



x Hall and Emmett: Univ. of 111. Agri. Exp. Sta 
2 See foot-note, page 138. 



•9 


92 


7 


7 


. 1 


90 


5 


9 


7 


87 


1 


12. 


.8 


86 


4 


13- 


.8 


85 


5 


14- 


•7 


79 





21 . 


.0 


77 


6 


22 


9 


72 


5 


27. 


•7 


70 


9 


29 


•5 


70 


6 


29 


. 1 


68 


7 


3i 


i. Exp 


Sta 


, 1912 


, Bu 



Pounds of 

boneless meat 

required to 

furnish 1000 

Calories. 

0.40 
O.46 
O.52 

0-54 
O.56 
O.70 
0-73 

0.86 
0.87 
0.88 
0-94 



:58. 



COST OF FOOD 



143 



sold at somewhat lower rates. Other animal foods, such 
as game and shad-roe, are plentiful only at certain seasons 
of the year. Vegetables which are difficult or expensive 
to cultivate, such as mushrooms, or are rare or transported 
long distances when out of season in a particular locality, 
bring high prices. 

The relation between supply and demand, and the lack of 
correspondence between food value and cost, is well illus- 
trated by meat. Studies of the food value of the various 
cuts bring out the fact that the cost of protein — and meat 
is most valuable because of its protein content — increases 

Cost of Lean and of Total Meat in the Various ReTail Cuts at Market 

Prices. 1,2 



Retail cuts. 

Steaks : 

Porterhouse, hip-bone 
Porterhouse, regular 
Club steak 
Sirloin, butt-end 
Sirloin, round-bone . 
Sirloin, double-bone 
Sirloin, hip-bone 
Flank steak . 
Round, first cut . 

middle cut . 

last cut . 

first cut . 

last cut . 



Round, 
Round, 
Chuck, 
Chuck, 



Roasts : 

Prime ribs, first cut . 

Prime ribs, last cut . 

Chuck, 5th rib . 

Rump .... 
Boiling and stewing pieces 

Round pot roast 

Shoulder clod 

Shoulder pot roast . 

Rib ends .... 

Brisket .... 

Navel .... 

Flank stew . 

Fore shank stew 

Neck 



Soup bones: 

Round, knuckle . 
Hind shank, middle cut 
Hind shank, hock 
Fore shank, knuckle 
Fore shank, middle cut 
Fore shank, end . 









Cost per 




Retail 


Cost per 


pound of 


Diagram 


price per 


pound of 


lean and fat 


number, 


pound of 


lean meat in 


meat in 


p. 176. 


cut, cents. 


cut, cents. 


cut, cents. 


8 


25 


38.6 


28.9 


10 


25 


40.2 


27.2 


18 


20 


32.1 


22.6 


I 


20 


25-3 


20.6 


3 


20 


28.3 


21. I 


5 


20 


28.7 


22 .7 


7 


20 


32.3 


24.2 


1 


16 


19-3 


16.0 


2 


15 


17.0 


15-3 


6 


15 


17-3 


15.6 


14 


15 


19-3 


l6.0 


2 


12 


18.3 


14. I 


9 


12 


15-7 


13- 1 


1 


20 


40.5 


22.9 


4 


16 


26.1 


18.8 


1 


15 


22.8 


17-3 


1 


12 


19.4 


12.8 


16 


10 


11. 6 


10. 1 


14 


10 


12.3 


10.5 


11 


10 


14-3 


11. 6 


3 


8 


16.2 


9.2 


1 


8 


150 


8-7 


2 


7 


12.8 


7-7 


2 


7 


10.9 


7-i 


1 


7 


8-5 


7.0 


15 


6 


8-5 


7.0 


2 


5 


26.3 


12.5 


18 


5 


7-5 


6-3 


19 


5 


62.5 


26.6 


2 


5 


17.2 


12.5 


4 


5 


12.5 


9-4 


6 


5 


28.8 


20.9 



1 Hall and Emmett: Univ. of 111. Agr. Exp. Sta., 1912, Bull. 158. 
2 See foot-note, page 138. 



144 NORMAL FEEDING AND FOOD ECONOMICS 

roughly 175 per cent, from the tougher cuts to the most 
expensive cuts of beef. As the result of the high price of 
meat during the war and the consequent demand for the 
"cheaper cuts" of meat the cost of such cuts has increased 
more in proportion than the more desirable cuts. 

The relative costs of the protein for 1000 Calories in the 
various cuts of beef are indicated in the tables on pp. 142-143 
which may be used in conjunction with the table and charts 
on pages 174-176. 

The cost of lean beef is a rough index of the relative econ- 
omy of steaks and roasts; in comparing boiling and stewing 
meats, however, the cost of both fat and lean, gross meat, 
should have more weight because in the utilization of these 
cuts the fat is usually incorporated with the lean in the form 
of meat loaf, hash, hashed meats (Hamburger steak), and 
corned beef. Since soup bones are of particular value for 
their flavoring material, their food value is not entirely 
comparable with the other portions of the carcass, as can 
be seen from the table. From the table we can see that the 
cheap cuts of meat actually furnish protein at a much lower 
price than the expensive cuts. It is to be remembered that 
in purchasing cheaper cuts of meat one often receives a 
larger proportion of connective tissue with its incomplete 
protein, gelatin, than in the case of the more expensive 
cuts; this lowered food value is, however, more than com- 
pensated by the decreased cost of the complete protein. 

Fish may be used to vary the diet or as a source of rela- 
tively cheaper protein food; they are practically inter- 
changeable with meat and are in general less expensive. 

In considering animal and vegetable food from an eco- 
nomic point of view, it is necessary to know whether the 
food-stuffs of the same kind which they contain are of equal 
value to the body; otherwise the apparently cheaper food 
may be in the end actually more expensive. Such con- 
siderations are particularly important with regard to pro- 
tein. Comparative studies of the digestibility of foods have 
shown that as ordinarily prepared the protein of animal 
food is more completely absorbed than the protein of vege- 
tables — meat protein, 91 to 97 per cent.; vegetable proteins, 
80 to 85 per cent.; bread protein, 70 per cent.; rye protein, 
40 to 76 per cent.; barley protein, corn protein, 61 to 83 
per cent. The lower degree of absorption of vegetable pro- 
teins is due chiefly to the cellulose layer which surrounds 
the protein and prevents its digestion. A larger amount 
of total food in general must be ingested to obtain the same 
amount of protein from vegetable than from animal pro- 



COST OF FOOD 145 

tein. In finely ground cereals and legumes, however, the 
protein has been found to be as thoroughly digested as 
animal protein. Certain vegetable proteins are low in their 
content of the amino-acids necessary for growth and main- 
tenance; but associated with these are other proteins which 
contain the necessary amino-acids. Consequently the nat- 
ural mixture of proteins is more or less complete and unless 
particular isolated or concentrated deficient proteins are 
involved, vegetable proteins may be used as the sole source 
of protein. That animal proteins are more efficient in satis- 
fying the body needs than vegetable proteins has been found 
in studies of the comparative utilization of animal and vege- 
table proteins. A comparison of proteins of different origin 
on the basis of their availability (biological value) to the 
body has shown that the different quantities of protein 
indicated when added to a carbohydrate diet will protect 
the body from protein loss after it has been reduced to a 
minimum on a purely carbohydrate diet: 

Grams 

Meat protein 30 

Milk protein 31 

Rice protein 34 

Potato protein 38 

Bean protein 54 

Bread protein 76 

Indian corn protein 102 

It is evident, therefore, that naturally occurring protein 
mixtures of vegetable origin are not as efficient as animal 
protein and that larger quantities must be ingested not only 
because of their lower digestibility but also of their lower 
biological value. 

The economic question with regard to the use of proteins 
of animal and vegetable origin therefore resolves itself into 
which is cheaper, the ingestion of a large amount of vegetable 
protein or a smaller amount of animal protein. The answer 
must be tempered by a consideration of the increased ac- 
tivity of the body required to metabolize and to excrete 
the excessive unavailable amino-acids of vegetable origin 
and of the possible effect of such increased activity upon 
the general well-being of the body. It is impossible at 
present to answer the question. When our knowledge of 
the amino-acid content of proteins is sufficiently developed 
we may be able to furnish the deficient amino-acids of an 
economical diet with comparatively small quantities of a 
more expensive protein. Even now we recognize the ad- 
visability of using a certain proportion of protein of animal 
origin with vegetable protein, for safety; there are very 
10 



146 NORMAL FEEDING AND FOOD ECONOMICS 

few diets which do not contain such protein, at least in 
the form of milk, eggs, or cheese. The inclusion of protein 
of animal origin in the diet is commendable from another 
point of view, for with the animal protein is purchased a 
certain amount of fat, a food of high caloric value. This 
addition of fat is desirable because it reduces the quantity 
of bulky carbohydrate food which must be ingested to meet 
the energy requirement of the body and also because it 
meets the need of a certain proportion of fat which would 
otherwise have to be purchased separately and added to 
the diet. 

A diet consisting largely of vegetables has been objected 
to on the ground that it is bulky; that a large quantity of 
food must be eaten in order to obtain sufficient protein, 
or else one must live on a low protein diet, for, with the 
exception of legumes and nuts, vegetable foods are rela- 
tively poor in protein. Since hunger is satisfied not so 
much by the quality of the food as by the quantity which is 
ingested, the appetite is in danger of being satisfied before 
sufficient material has been consumed to supply the protein 
requirement. For this reason and because vegetable pro- 
teins are less completely absorbed and less efficient in the 
body economy than animal protein a strictly vegetable diet 
is likely to be a low protein diet. 

It has been maintained by people who restrict their diet 
largely to vegetables, that they are able to utilize their food 
more efficiently and that the body activities take place at a 
lower level than those who eat meat. Benedict has shown, 
however, that the basal metabolism of vegetarians is not 
essentially different from that of those living upon a mixed 
diet. It is possible that a vegetarian may be able to live on 
a low protein diet more readily than a man upon a high pro- 
tein meat diet, because of the retarding effect of the indi- 
gestible cellulose upon the rate of digestion and of the 
absorption of products of digestion of vegetable proteins. 
Experiments have shown that the admixture of indigestible 
material results in a more uniform rate of excretion of 
nitrogen in the urine than in the absence of such material ; 
the inference is that the absorption from the intestine is 
likewise slower. On a vegetarian diet, then, instead of the 
rapid absorption of protein products of digestion and the 
disintegration of the excess characteristic of a high protein 
meat diet, the material is absorbed more slowly and the 
amino-acids are consequently more completely utilized for 
actual processes of repair and of growth. Proof of this 
fact has been presented in which a man was able to main- 



COST OF FOOD 147 

tain nitrogen equilibrium on a lower plane of protein in- 
gestion when food was taken in small amounts a number 
of times a day than when food was taken less often. 

In determining the value of a diet from an economic point 
of view consideration must be given to the quantity, pro- 
portion and kind of inorganic salts which it contains. While 
the average mixed diet contains a sufficient quantity of 
calcium, phosphorus and iron for the needs of the normal 
adult, the diet of children and nursing and pregnant women 
requires special attention in order that the mineral con- 
stituents be present in suitable proportions. A diet to be 
satisfactory with regard to its content of inorganic con- 
stituents must have the salts present in quantities which 
will meet the needs of the body and in such a form that the 
ash does not predominate potentially in acidic constituents 
— the same applies to foods which are potentially basic 
but to a much less degree, for an excess of base is not as 
harmful as an excess of acid. 

From a consideration of the kinds and quantities of inor- 
ganic elements in foods it is evident that the vegetable foods 
and eggs are, in general, rich in calcium, iron and phosphorus 
and yield an alkaline ash (oatmeal yields an acid ash), while 
the ash of the egg is acid ; meat is rich in iron and phosphorus 
and poor in calcium and has an acid ash; milk and cheese 
are rich in calcium and phosphorus, poor in iron ; milk yields 
an alkaline and cheese a slightly acid ash. Certain foods, 
particularly the prepared and purified products of both 
plant and animal origin, such as the fats and sugars, are 
very poor in salts. 

A diet in which vegetables and milk or cheese are the 
chief source of protein will therefore be predominately basic 
and contain, from a quantitative point of view, the most 
important inorganic constituents. In such a diet the low 
iron content of milk or its protein products is compensated 
by the relatively high iron content of vegetables. A diet 
in which meat or eggs predominate will, on the other hand, 
tend to lower the alkaline reserve on the body, because of 
the acid ash, and meat will at the same time be deficient 
in calcium, while eggs will furnish this element in compara- 
tively large amounts. Milk and cheese are therefore much 
more desirable not only as an economical source of animal 
protein but also for the salts contained in them. They 
can be included to advantage in a diet even when their 
cost is comparatively high. Eggs are next in order when 
the ash constituents are considered, and meat is the most 
expensive. 



PART II. 

FOODS 



CHAPTER VII. 

INTRODUCTION— MILK. 

The preceding chapters have dealt with the digestion, 
absorption and utilization of food; and the factors which 
determine the quantity and nature of food required for the 
needs of the human body. The discussion was confined 
almost entirely to the materials which are the basic ingredi- 
ents of food — protein, carbohydrate, fat, salts, water, and 
vitamines. Oxygen is also a food; its presence is so general, 
however, that it is ordinarily omitted from a quantitative 
discussion of diet. Any food in the general sense is com- 
posed of one or more of these ingredients. One food may 
contain a preponderance of protein, another of fat, etc. 
For the discussion of the various foods, a basis of classi- 
fication is necessary. A classification may be based upon 
the origin or composition of foods, or on the need which 
they supply. In the following chapters we classify foods 
according to their composition in terms of food-stuffs. For 
complex foods the particular food-stuff for which they are 
most valuable to the body determines the placement of 
them in the classification. Thus, we shall consider protein 
foods; fat foods; carbohydrate foods; and foods valuable 
for their salts, water, or vitamines, such as fruits, condi- 
ments, and beverages. A classification of this kind not only 
emphasizes the principal use of the food, but also aids in 
the search for foods that supply the elemental food factors; 
and it differs from the usual method of considering only 
the origin of foods in that there is no distinction recognized 
between vegetable and animal food. The dried legumes are 
placed with the protein-rich foods and certain animal prod- 
ucts are placed with the fats. There is one food, however, 
which is difficult to classify under these circumstances but 
which is of sufficient importance to be considered alone, 
viz., milk, for it is the most complete food available. 



150 MILK 

A more recent subdivision of foods has been suggested 
by McCollum. Certain foods are of such a constitution 
that they contain some of all of the necessary food factors, 
and particularly those most likely to be deficient in other 
foods, i. e., adequate protein, inorganic salts, and the vita- 
mines. Milk and the leaves of green vegetables are of this 
class. Such foods have been designated protective foods. 
The grains, seeds (bean and pea), meat, roots and tubers 
are deficient in one or more of the food factors, although 
they contain considerable amounts of protein, fat or carbo- 
hydrate. The grains, seeds, roots and tubers are deficient 
in the character of the protein, inorganic salts and fat-soluble 
A. Meat is deficient in calcium and fat-soluble A. 

MILK 

Milk is one of the most important foods in the human 
diet. It contains adequate protein, calcium, phosphorus, 
and the fat-soluble vitamine in considerable amounts. The 
water soluble vitamine and the anti-scorbutic vitamine are 
present to a fair degree. Milk is very poor in iron. As a 
supplement to the dietary deficiencies of the seeds and grains 
milk is invaluable. Lusk has stated that a family of five 
should not buy meat until it has bought three quarts of 
milk. 

Milk 1 is a complex food — a product of the activities of the 
mammary gland — prepared for the nourishment of the grow- 
ing young. It is a whitish liquid with a characteristic odor 
and sweetish taste. The white color is due to the emul- 
sified state of the fat and to the opalescence of the case- 
inogen solution. A slight yellowish tinge is imparted to 
milk, particularly when rich in fat, by certain coloring mat- 
ters. This pigment apparently comes from the coloring 
constituents of plants (see p. 232) and consequently varies 
in amount with the diet. A lactochrome, which is similar 
to urochrome in urine, occurs in the whey of milk. 

The specific gravity of milk varies between 1.027 and 1.035. 
Two counteracting factors influence the specific gravity of 
milk — the fats, which tend to lower it, and the other solid 
constituents, protein, carbohydrates and salts, all heavier 
than water, tend to increase it. The specific gravity is not 
necessarily a criterion of purity, for a skimmed, diluted 
milk may have the same specific gravity as fresh milk. 
Milk is an amphoteric liquid and is approximately neutral 

1 We shall confine our present discussion largely to the milk of the cow. Unless 
otherwise designated the term milk refers to cow's milk. 



MILK 151 

in reaction, hydrogen-ion concentration 2.6 x 10- 7 gram mole- 
cules. Human milk is slightly more alkaline 0.6-1. 1 x 10- 7 . 
The freezing-point of milk is -0.55 C. 

A microscopic examination of milk reveals the presence of 
fine droplets of emulsified fat, leukocytes, and bacteria, 
particularly streptococci. Milk that has not been carefully 
handled will contain dirt, and in some cases pathogenic 
bacteria. Bacteria may come from the udder itself or from 
the air. Leukocytes are normal constituents of milk that 
increase in number when the udder is diseased. With proper 
precautions milk which will contain very few bacteria (200 
to 500 per cubic centimeter) may be obtained from a healthy 
cow. The number of bacteria per cubic centimeter has been 
taken as a standard of purity. The following values are 
those recommended by the Commission on Milk Standards 
as the maximum for each grade. 

Number of Bacteria Permitted in the Various Grades of Milk. 

Bacteria count shall not exceed per 
cubic centimeters. 

After 
Before pasteurization 

Grade. pasteurization. at time of delivery. 

A 200,000 10,000 

B 1,000,000 50,000 

C +1,000,000 -50,000 

Non-pathogenic bacteria have very little effect upon adults 
but appear to be detrimental to infants. It is essential, 
then, that infants receive a milk containing very few bac- 
teria. For the adult a milk of low bacterial count is desir- 
able because of the greater probability of the absence of 
pathogenic organisms. 

Chemical Properties. — Milk contains all of the food- 
stuffs necessary for the growing organism: protein, fats, 
carbohydrates, vitamines, and salts are present in amounts 
best adapted to the young for which it is prepared. It is a 
most satisfactory dietary constituent in the regimen of the 
adult. Water is quantitatively the most important con- 
stituent of milk. It exists to the extent of from 80 to 90 
per cent., the average being about 87 per cent. 

Milk may readily be separated into products which are 
particularly rich in one or more of its constituents. By 
gravity, or more rapidly by centrifugalization, the greater 
proportion of the fat may be removed as cream. Con- 
glomeration of the fat droplets gives butter; coagulation 
with rennin or precipitation with acid separates casein or 



152 



MILK 



caseinogen respectively from the other proteins, salts and 
lactose. 

The following tables give the percentage composition of 
milk and various milk products arranged in the order of 
their increasing fat content. 

Milk and Its Products Arranged According to Their Increasing 
Fat Content. 



Centrifuged milk 
Skim milk . . . 
Buttermilk .... 
Whole milk ) 

Rennin coagulated milk i 
Evaporated (unsweetened) 
Condensed (sweetened) plus cane 

sugar, 41 per cent 
Curds 

Cream, usual 
Cream, fat 
Dried (whole) 
Cream, very fat 
Butter . . 



Fat, 
per cent. 

0.2 j 

0.6! 
0.6 



3-5 
8-3 

9.0 
10. o 
150 
20.0 
28.5 
30.0 
85-0 



Protein, 
per cent. 



3 
3 
3-7 
7-5 

5 
o 
o 
o 

3 
o 

5 



Carbohydrate, 
per cent. 



4 
4 
4 
9 

13 
3 
4 
4 

36 
4 



Milk and Its Products Arranged According to the Protein Content. 



Whey 

Whole milk \ 

Rennin coagulated milk J ' 
Evaporated (unsweetened) 
Condensed (sweetened) plus 

sugar, 41 .0 per cent. 
Curds (cottage cheese) 
Cheese, fat . 
Cheese, medium fat 
Cheese, skim milk 
Dried (whole) 



Protein, 

per cent. 

0.8 



3-7 

7-5 



8-5 
10. 
27.0 
35-0 
35o 
24-3 



Fat, 
per cent. 
0. I 

3-5 

8-3 

9.0 

11. 
30.0 
10. o 

4.0 

28.5 



Carbohydrate, 

per cent. 

5-0 

4-4 
9-7 

13 -3 (54-3) 
3-0 



36.8 



Protein. — The proteins of milk constitute about 3 per 
cent, of the total weight or 25 per cent, of the solid con- 
stituents. Of the three predominating proteins in milk, 
lactalbumin, lactoglobulin and caseinogen, the latter pre- 
sents the most characteristic properties. Caseinogen 1 be- 
longs to the class of conjugated proteins called phospho- 
proteins. It is an acid protein, insoluble in dilute acids 
and dissolved by alkalis. Neutral solutions of caseinogen 
are not coagulated by boiling but a pellicle is formed, such 
as is observed upon boiled milk. The flocculent precipita- 
tion observed in sour milk consists of caseinogen which 

1 There is a certain confusion in the use of the terms caseinogen, the protein 
existing in fresh milk, and casein, the product of the action of rennin upon casein- 
ogen. (Halliburton: Jour Physiol., 1900, ii, 448). Certain authors, particu- 
larly the German writers, designate the protein of fresh milk as casein and the 
clot as paracasein. 



MILK 153 

has become insoluble in the acid (lactic) produced by the 
action of bacteria upon the lactose. The changes in the 
protein molecule are simple and appear to involve only 
processes such as occur in the precipitation of inorganic 
substances. Precipitated casein may be dissolved by the 
addition of an alkali; water-soluble casein preparations are 
of this nature. 

The phenomena of the coagulation of milk by rennin also 
concerns caseinogen. The transformations are more pro- 
found than those mentioned above for sour milk. In this 
case the caseinogen is split into two molecules of casein or 
perhaps into a soluble whey, albumose and casein. The 
calcium salts of casein are insoluble; in the presence of soluble 
calcium salts calcium caseinate is formed and the char- 
acteristic clot is produced. The coagulum formed holds by 
absorption or entanglement certain quantities of fat and 
lactose. A comparative study of cow's milk and human 
milk shows that the quantity of caseinogen is greater in 
cow's milk than in human milk. 

Lactalbumin and lactoglobulin have not been shown to 
differ materially from the albumins and globulins of blood 
serum. The albumin forms about 0.6 per cent, of the whole 
milk or 15 per cent, of the proteins, while the globulin exists 
only in traces. Minute traces of fibrin and a protein called 
opalisin have been detected. 

Fats. — The fat in milk is a mixture of several different fats, 
the more important of which are the triglycerides of palmitic, 
stearic, and oleic acids, and to a less extent of myristic, 
butyric, caproic, caprylic and capric acids. Fat is the most 
variable constituent of milk, the proportion may vary from 
25 to 2 per cent.; the average is between 3 and 4 per cent. 
Further discussion of the fats of milk will be found under 
butter, p. 232. Milk is also rich in fats with low melting- 
points; factors which tend toward increased digestibility. 
Milk fat exists normally in the form of a fine emulsion. 
The degree of emulsion of fat in milk differs with the various 
breeds. The greater availability of the fat from the milk 
of the Holstein cow over that of the Jersey cow is ascribed 
to the finer state of division of the fat of the former. The 
value of condensed milk in the feeding of some infants has 
been ascribed to the fact that such milks are "homogenized" 
and consequently the fat is very finely divided. 

Carbohydrates. — Lactose, or milk-sugar, the principal 
carbohydrate constituent of milk, is a specific product of 
the mammary gland. Chemically it is a disaccharide. Hy- 
drolysis, as in digestion, yields a molecule each of galactose 



154 MILK 

and glucose. Compared with cane-sugar from which it dif- 
fers only in the arrangement of its atoms, lactose is not as 
sweet or as soluble. These properties account in part for 
the use of lactose as a vehicle for drugs and, the lack of 
sweetness particularly, for its use in diets which must have 
a high caloric value and still be completely assimilable. 
Lactose is dextrorotatory, has a strong reducing power and 
is not fermented ordinarily by yeast. Alcohol and lactic 
acid are formed from it by the action of certain bacteria, 
chiefly Bacillus lactis acidi and yeast. In these processes 
lactose is first hydrolyzed into its monosaccharide compo- 
nents and then transformed into alcohol or lactic acid, 
according to the organism concerned. The production of 
lactic acid commonly occurs in the souring of milk. Alco- 
holic fermentation is induced in the preparation of "kou- 
myss" and "kefir." The quantity of lactose in cow's milk 
varies from 4 to 6 per cent, of the whole milk, the average 
being about 5 per cent., or 38 per cent, of the total solids. 

Salts. — The salts, inorganic and organic, consist of com- 
binations of calcium, magnesium, sodium, potassium, and 
iron with the acid radicles of hydrochloric, sulphuric, phos- 
phoric and citric acids. In addition there are probably 
combinations of these substances with the proteins. The 
proportion and importance of the salts in milk will be con- 
sidered later (p. 156). 

Besides their direct food value, particularly for bone for- 
mation, the combinations of calcium and the phosphoric 
acid radicle, calcium phosphates are associated with the 
caseinogen in its natural state and are concerned in the 
coagulation of milk by rennin. 

The modification of cow's milk for infants by dilution 
with water, lime water, etc., reduces the proportion of salts 
in the modified milk. Forbes suggests the use of whey 
for the dilution of milk which permits the reduction of the 
quantity of caseinogen without reducing the proportion of 
the other constituents, particularly the salts. 

The iron content of milk varies with the species. Cow's 
milk contains a half to a fifth as much as human milk; 
human milk, 1.6 to 1.7 milligram of Fe 2 3 per liter; cow's milk 
0.3 to 0.7 milligram of Fe 2 (X per liter. This marked diff- 
erence indicates that children fed on cow's milk get much 
less iron than when fed on human milk; a difference which is 
increased when cow's milk is diluted with water. 

Citric acid is present in cow's milk to the extent of approx- 
imately 0.1 per cent., roughly three times as much as in hu- 
man milk, 



MILK 155 

Studies of the rate of growth of rats have demonstrated 
that there, are in milk certain materials which belong to the 
group of accessory substances or vitamines. Milk contains 
fat-soluble A and water-soluble B and the anti-scorbutic 
vitamine. It apparently contains a smaller proportion of 
the last two vitamines than is found in some vegetables and 
fruits. 

The constituents of the milk of any species are qualita- 
tively the same. Slight quantitative differences exist due 
to individuality, the course of lactation, the change of seasons, 
and the time of milking, night or morning, the first milk 
drawn, or the last, etc. Variations in the diet have little 
effect upon the composition of milk. However, the composi- 
tion of milk fat may be affected by feeding foreign fat; the 
fat tends to acquire the characteristics of the ingested fat. 
Milk of different species differs chiefly in amount rather 
than in kind of the constituents present. 

The composite milk of a herd of cows, or from a city dairy 
is quite uniform in composition, although showing slight 
seasonal variations. Protein and fat are higher in the 
autumn and winter than in the spring and summer. Lactose 
remains fairly constant throughout the year. Generally 
the predominating breed of cow influences the percentage of 
fat. Individual variations within a given herd, however, 
have been shown to be as great as the variations between 
breeds of cows. The following table gives the composition 
of cow's milk. 1 

Composition of Milk. 

f Water =87.1 



Fat =3-9 (Casein = 2.5 

I ( Nitrogen compounds = 3.2 I Albumin = 0.7 

Solids — 12.9 J I ( 

\ 1 3-2 

Milk = 100 \ 100. J Solids not fat = g.oJ 

I A Milk-sugar =5-1 

v 12 .0 J Ash (salts) =0.7 

{Carbon dioxide / 

Nitrogen V 9.0 
Oxygen 

Substances foreign to milk appear in it when fed to a lac- 
tating animal. Thus strong flavors occur in milk as the 
result of certain diets; the peculiar taste of milk when the 
cows begin to graze in the spring is due to certain foreign 
constituents derived from the green food which have been 
transferred to the milk. Drugs and narcotics have been 
shown to appear in milk following their ingestion. 

Variations in Composition. — Milk of different kinds of 
animals shows very striking variations in the proportions of 

1 United States Public Health and Marine Hospital Service, 1900, Bull. 56. 



156 MILK 

their constituents. The accompanying table shows the 
composition of human and cow's milk. 

Protein. 
Water. Caseinogen. Albumin. Fat. Lactose. Salts. 

Human milk . 88.5 1.2 0.5 3.3 6.0 0.2 

Cow's milk .87.1 3.0 0.53 3.7 4.8 0.7 

A consideration of this table, with its many differences 
and the favorable growth of all young, emphasizes the fact 
that there is an elaboration of milk best adapted to the young 
of the particular species. Milk of one species when fed to 
the young of another may, as we know is the case in infant 
feeding with cow's milk, prove deficient in one constituent 
and excessive in another and thus be entirely unsatisfactory. 

The adaptation of milk to the young of a species has been 
shown to be pertinent in the case of the inorganic constitu- 
ents as well as in the organic constituents. The similarity 
of the composition of the ash of the young and the ash of the 
milk has been shown by Bunge and others. The following 
table gives the ash constituents of the young and milk of the 
rabbit, dog, and man, and the milk of the cow. 

Comparison of the Composition of the A.sh of Milk with That of the 
Newborn Young for Which It is Intended. 















Rabbit 




Puppy 




Human 




Cow's 


Rabbit's 


14 days 


Bitch's 


few 




milk. 


Infant. 


milk. 


milk. 


old. 


milk. 


hrs. old 


Potassium (K2O) . 


35-2 


6.2 


22. I 


10. I 


10.8 


15.0 


II. I 


Sodium (Na 2 0) . 


10.4 


8 


1 


139 


7-9 


6.0 


8.8 


10.6 


Calcium (CaO) 


14.8 


40 


5 


20.0 


35-7 


35 


27.2 


29-5 


Magnesium (MgO) 


2.9 


1 


5 


2.6 


2.2 


2.2 


1-5 


1.8 


Iron (Fe20s) . 


0.18 





39 


O.O4 


0.08 


0.23 


0. 12 


0.72 


Phosphorus (P2O5) 


21.3 


35 


3 


24.8 


39-9 


41.9 


34-2 


39-4 


Chlorine (CI) . 


10.8 


4 


3 


21.3 


5-4 


49 


16.9 


8.4 



It will be seen that the species which rapidly increases in 
weight, a milk is secreted with ash constituents that are 
quite similar to those of the young, while for the more slowly 
growing organisms, as man, there is a discrepancy between 
the two. 

Condensed Milks. 1 — Milk is condensed (a) thorough evap- 
oration in a vacuum, condensed (sweetened) milk and evap- 
orated milk and (b) by drying. The products of the first 
class retain a considerable quantity of their moisture and 
depend upon canning and sterilization for their preservation 
while the milks of the second class are sufficiently dry to keep 
for long periods of time without further sterilization. A 

1 For a discussion of condensed milk and its relation to infant feeding see bulle- 
tin on "Milk," by Mendenhall, U. S. Dept. Labor, Children's Bureau. 



MILK 157 

further advantage of the dried milks is that when the con- 
tainer is once opened it is not imperative to make immediate 
use of the product to prevent spoilage. The relative value 
of any of the condensed milk products depends upon the man- 
ner in which the original milk is handled, and this is particu- 
larly so of the dried milks. 

Evaporated (unsweetened condensed milk) milk has had 
from one half to three fifths of its water removed by evap- 
oration. It must contain 25.5 per cent solids and 7.8 per 
cent fat. This milk is put up in cans and sterilized. The 
degree of sterilization varies ; it appears that very few evap- 
orated milks are actually sterile. Most brands of this 
class of milk will keep for long periods particularly if kept in 
a cool place. 1 Condensed (sweetened) milk depends upon 
the addition of approximately 40 per cent of cane sugar to 
assist in its preservation. The high sugar content is ob- 
jectionable for many purposes. Condensed milk must con- 
tain 28 per cent, of total milk solids and 8 per cent, of fat. 

Dried milks have been prepared on an extensive scale for 
only a comparatively short time. They may now be had in 
the form of skimmed milk, half-skimmed milk and whole 
milk. These milks particularly skimmed milk have been 
used extensively in the manufacture of candy, milk choco- 
late and bakery products. The value of milk powders varies 
considerably according to the method of manufacture The 
best powders are made from fresh milk and are subjected 
to the influence of heat for a very short time. Such milks 
when mixed with water "dissolve" readily and are hard to 
tell from fresh milk. Skimmed milk powder mixed with 
butter in a special machine was found to be very satisfactory 
in the hospitals in the army where fresh milk could not be 
obtained. The following table gives the composition of 
condensed milks. 



Composition of Condensed Milks — in per cent. 

Conder 
(sweeter 

fat 9.0 



Condensed Dried Skimmed 

(sweetened). Evaporated. whole milk. 

3 28.5 



■<K?: : : : : A\ I 

ash 1.8 1 

Cane Sugar 40.9 

Water 26.5 73 



5 24.3 33 

7 36.8 55 

5 5-6 

o 4.8 



In condensing milk most of the biological properties are 
retained. The value of the protein remains practically 

1 Evidence of spoilage is easily detected through the swelling of the can. Oc- 
casionally spoilage occurs without swelling due to the growth of an organism 
without the production of gas; this is called "flat sour." 



158 MILK 

unchanged. Fat-soluble A and water-soluble B are only 
partially destroyed. What the effect of storage may be is 
not known. The anti-scorbutic vitamine is apparently 
destroyed. There is a possibility that dried fresh raw milk 
may retain a part at least, of its anti-scorbutic properties. 
If any of these products are to be used for infant feeding it 
is well to supplement it with fruit or vegetable juice to supply 
the anti-scorbutic vitamine. For infant feeding, milk powder 
has been found very satisfactory and likewise evaporated 
milk. The condensed milk contains too much cane-sugar 
for infant feeding. 

Influence of Temperature — Bacteria. — Milk when drawn 
from the mammary gland contains, in addition to the food- 
stuffs, organisms and substances, such as leukocytes, bac- 
teria, and enzymes. If raw milk be permitted to stand at 
ordinary temperatures, particularly when exposed to the 
air, physical and chemical transformations take place. 
These are chiefly bacterial; changes caused by leukocytes 
and the enzymes secreted with the milk are of little practical 
importance. 

The bactericidal properties of milk prevent the initial 
rapid growth of bacteria. Raw milk exhibits, at room 
temperature, an apparent inhibition of bacterial growth; in 
some cases a destruction of bacteria has been demonstrated. 
The restraining action of raw milk extends over a period of 
from twelve to twenty-four hours; after this time a rapid 
multiplication of bacteria takes place. This increase is re- 
tarded at low temperatures, 15 C. and below. When heated 
to 8o° C. or above milk loses its power to restrain bacterial 
growth. There is a more profound change in the latter case, 
for such milk permits a rapid growth of the bacterial organisms. 
Heated milk may therefore become more dangerous than 
unheated milk unless care is taken to prevent reinoculation 
of the heated product, otherwise a greater number, and 
perhaps more virulent types, of bacteria may develop than 
would have developed in unsterilized milk. 

The presence of pathogenic organisms in a heterogeneous 
milk supply, however, demands some means of killing them 
or restraining their growth, such as sterilization or pasteuri- 
zation. In pasteurization milk is heated to 6o° to 70 C. 
(140 to 160 F.) for from ten to twenty minutes. As the 
result of this treatment practically all of the bacteria are 
destroyed. Such a temperature does not affect the spores, 
hence milk must be cooled and kept at a temperature which 
will inhibit or restrain their development. Heating to a 
temperature of 6o° C. for twenty minutes has been shown to 



MILK 159 

have little effect upon the germicidal power of milk or upon 
the enzymes present in it. Sterilization is the process of 
destroying all of the organisms present, both bacteria and 
their spores. Complete sterilization can only be accomp- 
lished by long-continued boiling or intermittent heating 
below the boiling point. Such a procedure also destroys 
the enzymes and the germicidal property of milk. In both 
pasteurization and sterilization the water-soluble accessory 
substance is destroyed. 

Action of Bacteria. — Bacteria, which produce unusual and 
abnormal products, find their way into milk as the result of 
carelessness in handling. They cause alterations in the 
color, odor, and taste of milk. The formation of blue milk, 
or red milk, of slimy or ropy milk, and the development of a 
bitter taste are the result of bacterial action. Certain 
yeasts cause alcoholic fermentation. 

Lactic acid is the most important of non-pathogenic 
bacterial action in milk; it is the predominating substance 
formed in the souring of milk. With the accumulation of 
the lactic and other acids the reaction of milk changes from 
approximately neutral to distinctly acid. Caseinogen is 
insoluble in this medium as shown by its precipitation, 
ordinarily called curdling. The precipitated caseinogen 
settles to the bottom of the liquid, leaving the "whey. " 
Whey contains all of the constituents of milk except the 
caseinogen and a portion of the fat with the addition of lactic 
acid, the loss of some lactose, and the transformation of a 
portion of the protein into its cleavage products. The phy- 
sical evidence of souring is often the secondary result of 
bacterial action rather than the direct consequence. 

Action of Heat. — The first evidence of the effect of heat 
upon milk is the formation of a pellicle or skin upon its sur- 
face. If this skin is removed another immediately takes its 
place. An examination of this film shows it to consist chiefly 
of protein and fat. The evidence favors the view that the 
pellicle consists of protein (caseinogen) which has entangled 
the fat, for solutions of caseinogen when heated give the 
same kind of film. Surface evaporation and fat facilitate 
the formation of the skin but are not essential. If the milk 
be slightly acid, such as following bacterial action, heat does 
not produce a film but coagulation occurs. It is the presence 
of a small quantity of acid which causes the coagulation of 
apparently fresh milk in the process of pasteurization. 

When milk is heated to between 6o° and yo° C. most of the 
bacteria present in it are destroyed. Such heating has little 
effect upon the other constituents of milk. If the tempera- 



160 MILK 

ture be raised above 70 C, however, the composition, color, 
odor and taste are affected according to the extent of heating. 
The accessory substances or vitamines are at least in part, if 
not entirely, destroyed by heating. 1 The caseinogen is 
apparently affected by boiling when judged from its retarded 
coagulation with rennin. Pure solutions of caseinogen are 
not affected by heating, hence the retardation of coagulation 
may be due in part to the altered state of a portion of the 
calcium salts which have probably been precipitated as 
tricalcium phosphate. Experimental evidence indicates that 
there is no change in the digestibility of caseinogen as the 
result of heating, and it may even be an advantage for the 
curd of heated milk tends to be more flocculent than that of 
raw milk. The biological properties of milk — enzymes, 
etc. — are destroyed by heating. 

The albumins are coagulated in the process of heating. 
Studies on the change in the viscosity of milk when heated 
have shown that permanent coagulation takes place at 70 
C. The liberation of ammonia and of volatile sulphide, 
probably hydrogen sulphide, are indications of changes in 
the proteins. These last factors are probably partially 
concerned in the taste and odor of heated milk. If the 
boiling be sufficiently long continued, milk acquires a brown- 
ish color from the modification of the milk-sugar, lactose. This 
change is similar to the browning of sugar or caramelization. 
The influence of heat upon the digestibility of milk will be 
considered later. 

Refrigeration of milk retards the growth of bacteria and 
the action of enzymes but these processes are not entirely 
inhibited. The changes in the composition of refrigerated 
milk are due principally to bacterial action. They consist 
in a gradual proteolysis or digestion of the casein, the fer- 
mentation of lactose, and the hydrolysis of fat. Proteolytic 
changes in the albumin are due to enzyme action; such 
changes are negligible in the ordinary period during which 
milk is kept. 

Digestion of Milk. — The coagulation of the milk protein, 
caseinogen, through the action of rennin, is the distinctive 
difference between the digestion of milk and that of other 
substances. Practically all other proteins are ingested in a 
solid state. Milk when swallowed passes into the stomach 
which contains the acid gastric juice. Under such condi- 
tions we might expect the caseinogen to be precipitated. 
This is not the case, however, for it has been shown that 

x The addition of orange or potato juice will tend to prevent the development 
of scurvy when pasteurized milk is used by infants. 



MILK 161 

milk is coagulated, clotted by the rennin, before acid precipi- 
tation takes place. The cause of this is to be found in the 
nature of milk, in its ability to absorb a considerable amount 
of acid without changing its reaction appreciably, and in the 
fact that the gastric juice is not secreted fast enough to fur- 
nish sufficient acid to precipitate the caseinogen before the 
rennin has transformed it into casein. 

The reason for the coagulation of milk before digestion is 
not clear. Milk can be digested completely in a test-tube 
without the formation of the insoluble casein. It may be 
that if the caseinogen were not coagulated, the milk would 
pass on into the intestine more rapidly than that organ could 
take care of it and digestive disturbances would result. 
Coagulated caseinogen must pass through the usual stages 
of gastric digestion; the intestinal juice continues and com- 
pletes its digestion. 

The coagulation of milk apparently concerns but two of 
its constituents, the caseinogen and the calcium salts. Ac- 
cording to the views of Hammarsten, caseinogen is hydro- 
lyzed through the action of rennin into two constituents, 
soluble casein and a peptone-ljke substance called whey 
protein. Soluble casein unites with calcium ions (soluble 
calcium salts), forming the insoluble calcium compound 
usually called casein, or calcium caseinate. More recent 
work has failed to discover the formation of this peptone- 
like substance in the process of hydrolysis by rennin. The 
present conception of the changes in the hydrolysis is the 
splitting of the caseinogen into two equal molecules of 
casein, which, being insoluble in the presence of soluble 
calcium salts precipitate out of solution, forming the clot. 
In the absence of soluble calcium salts hydrolysis occurs, but 
the formation of the insoluble clot does not take place until 
they are added. There is a tendency to ascribe to pepsin 
the changes we have assigned to rennin, i. e., to assume that 
rennin and pepsin are identical and the hydrolysis just de- 
scribed is the first step in the gastric digestion of caseinogen. 

The physical nature of the clot is influenced by the condi- 
tions under which it is produced. In the test-tube cow's 
milk gives a firm, tough, clot which finally contracts, squeez- 
ing out the whey. If the milk be agitated slightly, a fine 
flocculent precipitate is formed. This is probably the type of 
clot which is produced in the stomach rather than the tough 
clot usually described. The presence of fat influences the 
nature of the coagulum. Fat becomes entangled in the 
precipitated casein, causing it to form rather dense masses 
which show a tendency to coalesce; a distinction from the 
ii 



162 MILK 

flocculent, finely divided coagulum obtained with skimmed 
milk. This fact is of importance in the feeding of infants, 
and will be discussed later. Boiled milk is held to give a 
more flocculent clot than unboiled milk. 

Various methods are employed, particularly in the feeding 
of infants, to ensure a light flocculent clot and to increase 
its digestibility, such as the addition of barley water, dilu- 
tion with water or lime water, the addition of citrates, or 
heating. The addition of cream and coagulation before 
eating (butter milk) also ensures a finer curd, but these 
methods are restricted to adults. 

The intestine completes the digestion of milk. Here the 
proteoses, caseoses, are reduced to simpler complexes by the 
trypsin of the pancreatic juice and the erepsin of the intes- 
tinal juice. Erepsin has the ability of converting casein- 
ogeri into amino-acids, although it is unable to act on most 
other natural proteins. This is probably an important 
factor in digestion by infants who, it is affirmed, receive a 
part of the ingested milk from the stomach without its first 
having been acted upon by the gastric juice. Lactose and 
the fats are first acted upon extensively in the intestines, 



CHAPTER VIII 
PROTEIN FOODS 

The protein requirement of the human body is supplied 
from both the animal and the vegetable kingdoms. A 
closer analysis of the facts shows the latter to be the ulti- 
mate source of protein; for, at least so far as our present 
knowledge extends, only the plant is able to synthetize this 
essential food-stuff from inorganic matter. With one or 
two exceptions, however, we find that protein predominates 
in animal foods and that the latter are the chief source of 
this food-stuff in the human diet. 

In our previous discussion we considered the need for pro- 
tein, the general products of its digestion, the forms in which 
its decomposition products are excreted, and the quantity of 
protein necessary for the functioning of the body. These 
considerations have been confined so far as possible, to pro- 
tein in general. The consideration of the differences among 
proteins has been postponed until a discussion of the various 
kinds of protein food could be concluded. 

The various proteins in one organism differ from those in 
another. The proteins in the individual organisms are also 
of different kinds. Even proteins of the same kind from 
various sources are different in composition. These differ- 
ences are exhibited in the physical properties as well as in 
the chemical composition. The processes of metabolism 
are concerned with the utilization of these varied proteins 
for the maintenance of the supply of the various body pro- 
teins. 

A determination of the elements present in proteins shows 
them to consist of carbon, hydrogen, oxygen, nitrogen, and 
sulphur. These elements are combined to form amino- 
acids, the structural units of the protein. Phosphorus is 
also present in some proteins, while others contain traces of 
certain of the metallic elements, such as iron, copper, iodine, 
manganese, and zinc. A protein is, then, a combination of 
amino-acids as such, or in combination with certain non- 
protein substances, such as carbohydrates, lipins (fatty acids) 
purine bases, phosphoric acid, etc. In digestion the protein 
molecule is split by hydrolytic cleavage into simpler com- 
plexes — proteoses and peptones; these in turn give rise to 



164 PROTEIN FOODS 

less complex compounds, peptides, and finally amino-acids. 
It is through studies of the products of these hydrolytic 
cleavages that we have gained our knowledge of the consti- 
tution of protein. 

Consideration of the kinds and quantities of amino-acids 
present in proteins of various kinds and from different 
sources is not only instructive but necessary, for recent inves- 
gations have indicated the importance of relative quantities 
of amino-acids in the diet. 

The table on page 165 gives the proportions of the diff- 
erent amino-acids obtained from certain proteins. It is 
important to remember that every protein food is composed 
of a number of proteins and that the mass of total food at 
any meal is seldom deficient in any particular amino-acid. 

The protein content of food is usually estimated from the 
amount of nitrogen in it by multiplying this value by 6.25. 
This calculation is based on the fact that the average nitro- 
gen content of protein is approximately 16 per cent. This 
procedure is not entirely correct, for in different kinds of 
protein variations from 15 to 18 per cent, of nitrogen have 
been observed. Vegetable proteins are particularly high in 
nitrogen. The average for wheat protein is 17.55 per cent., 
which would give a factor of 5.7 instead of 6.25. 

Another error in the use of the value 6.25 is due to the 
fact that not all nitrogen in a food is present as protein; a 
certain proportion is present as extractive nitrogen. Calcu- 
lations of the protein content of foods based upon determi- 
nations of protein itself as compared with the calculated 
values for protein (N x 6.25) show that on the latter basis 
the flesh of different animals contains various amounts of 
protein, whereas actually they differ but little in their per- 
centage protein content. 

Protein. 

Determined 
Species. (N. x 6.25). by Janney. 1 

Chicken 19.3 16.6 

Fish (halibut) 18.6 16.5 

Ox 21.6 16.6 

Rabbit 20.8 16.3 

Cat 21. 1 178 

Dog 20.2 17.4 

Man 19.7 16.4 

The body proteins differ from one another and from the 
food proteins. Some proteins are entirely lacking in certain 
amino-acids. In our discussion of the protein requirement 
(p. 76) we saw that the effect of the absence of particular 

^anney: Jour. Biol. Chem., 1916, xxv, 85. 



PROTEIN CLASSIFICATION 



165 



ES 



•x 



•sdoiiBog 



qsid 



•U331DTB[3 



•ujoq dasqs 'upEiS^j 



■u^Bpo 



5.S 

op 



•(§33) 

U !II^!A 



uaSoupsB3 



•upz aziBp\[ 



•5B3qM 



•azrep^; 



•i^qM 



•(Bad) 
utuinSaq 



■ui^s^pa 



' u pqid 



•uiruas 9sjoh 



i-jt-OOb-NN 

NCO ©rH CO C\j 



00 w mm q< 

W ■* d t> _|_ i> > 



oo qo 
oo^oi 



co iaa>TS< oo oh 
oi co^i> i inc\ir-i 



O 00>*r-l^ 

© OOWN 



N 00 t-l •* m ?o ^ 

CO NO d~T|> NH 



t-CO N COCM 
ON rHCO N 



oo Nin m co m t- 

rH CO CO «6 ""J>Ni-i 



in©iono)<OHiot» 


lOMt- • N • • 


OrHTjtlOrHCO'Ht-CO 


N t-N • O ; ; 


IO00 i-l^ ■* 
COO 1 NOO© 


t-OCO OSCO OOTfrt* 

^MOONOMOO 


ooo505con< • 


•N 


■ NOlO O0O5CO 


OOHCSMW • 


•Tjt 


; NCO t-^ + ^fH rH 


OM^NlOiO 


t-MTjuooomoioto 


o -h t- oi co ■>* o 


tOOHiOMHOWH 

l-t 


O00 05 CO CO coo 


• o 


. t- CM CO O O 00 CO 


O 05 rH OS CO CO r-i 


: OT 


•HSOHOOOW 
N 


OO-^CO-^NNmN 


■ CO t-N O O CD N 


ONCOCONiHOOCO 


; oco cor-io om 


CO • • N0O0O • 


• o 


• t-C-rH ©OH 


O ; ; COrHCO • 


• lO 


; ON t> I COCO N 


tJ<CO • f-IOO> • 


•o 


• t-0*# NNiO 


OO ;»*rHi-t • 


;■* 


• 6^ I WHM 


■* i-i • ooo com 


• N 


•COOt- 0<*H 


ON • 00CO rH O 


• CO 


• lO i>r-i + d N N 



itoa^HcoMt-oineot-OH 

iMTOMNOOHN'iiHHTHrl 



O CO O O lOlfi 00 NCO ;©•* -CO 

co co rn in n co d r-i co -no : h 



ION t-00 10 ; OS00 ; "5 W • ; 

CON I OOOON : ON : N 00 : + : 



•(^B9qA\) 
uisoonaq 



I CO ID I NNr-l 



•(B3d) 

uiptunSsq 



•uiuinqiBiDBq 



io q t- q oq q 

© O ©d^ H 


i3 


• h qm ©coco 
■ xjl co d + CO N H 


lOO^-^Oi • 


• O 


•OHM • NHCO 


ONOONO • 


• <tf 


•HOM ■fflNH 



•uitijss asJOH 



t- 'OHHcpino i 1- ? 1 ^: :_i_ : : 

ON : dcONONH -COl> : I • : 



•S3g 



000 'IfliOH 'OH •HMW I NO 



•(aucqsiq) asjoq 
'uiqoiSouiaq jo uiqojo 



;N ;ONM(CMMO*l-* MO 
•■^ 'a^HOOMHTtiHlOT^H 



•(suiuiB^ojd) auiuqBg 



00 ;0 






... .'3 ... . •- o . a . . . 

rt c rt rt rt 

uc.S'cj co c-5-5 o.c3B.S a.SS S 
0<>h-1PhHwUhhO<0<H»-1K< 



166 PROTEIN FOODS 

amino-acids from the protein molecule, when used as the 
sole source of protein, was a failure to grow. In a previous 
chapter the inability of the body to synthetize protein and 
certain amino-acids was discussed (p. 76). The necessity 
for a liberal supply of the different amino-acids in the form 
of a varied selection of proteins, and for a kind of digestion 
that converts these structural elements in protein into 
readily available substances either as the amino-acids or 
simple complexes of these is therefore evident. Such a 
variety is obtained in the ordinary mixed diet; in special 
diets it is a factor to be considered. The influence of the 
ingestion of proteins homologous to those present in the body 
upon the minimum protein requirement has been discussed 

(p. 78).. 

Proteins are not ordinarily distinguished by their amino- 
acid content, however, but chiefly by their physical proper- 
ties. Differences in chemical composition are, however, 
the basis of distinction between the members of one group — 
the conjugated proteins. 1 

The following outline of the kinds of proteins and their 
characteristics, the classification adopted by the American 
Physiological Society and the American Society of Biological 
Chemists, will be adhered to in our discussion. This classi- 
fication differs from that of the English societies in a few 
instances; in most matters they are essentially identical. 

1. Simple Proteins. — Protein substances which yield only 
a-amino-acids or their derivatives on hydrolysis: 

(a) Albumins. 2 — Soluble in pure water and coagulable by 
heat. Albumins are present in all cells and in the important 
fluids of the body. Ovalbumin is the predominating protein 
of egg white. Other important albumins are serum-albu- 
min present in blood plasma, lymph and other body fluids; 
lact-albumin of milk; the vegetables albumins, leucosin of 
wheat, and legumelin of the pea. 

x The terms protein and proteid are often used together. The present-day 
German writers use the word protein to designate simple albuminous substances, 
and proteid for combinations with other complexes. The simple proteins and 
the conjugated proteins of the American classification are proteins and proteids 
respectively in the German classification. A distinction is sometimes made 
between protein and proteid among English-speaking writers. Proteid desig- 
nates definite chemical compounds, or isolated albuminous substances (our pro- 
teins), while protein is used to denote the mixture of proteids in a food, the 
measure of which is the quantity of nitrogen which the food yields upon analysis 
times 6.25, the average percentage of nitrogen in pure proteid. Protein has been 
adopted by English-speaking scientists as the generic term for the class of sub- 
stances which we are discussing — and we will use this term in that sense. 

2 A distinction is sometimes made between the pure individual substances 
alburm'w and a mixture of proteins occurring naturally together, or albumen, as 
the white of egg. The term albumen is used very little and is now practically 
restricted to the expression "egg albumen." 



PROTEIN CLASSIFICATION 167 

(b) Globulins. — Globulins are insoluble in pure water but 
soluble in neutral solutions of salts of strong bases with 
strong acids. Globulins are present in blood, serum globu- 
lin; egg, ovoglobulin; milk, lactglobulin ; seeds, edestin 
(hemp seed); legumin (pea). 

(c) Glutelins. -^-Glutelins are simple proteins insoluble in 
all neutral solvents but readily soluble in very dilute acids 
and alkalies, e. g., the vegetable protein, glutenin, from wheat. 

(d) Alcohol Soluble Proteins {Prolamines). — Simple pro- 
teins soluble in 70 to 80 per cent, alcohol, insoluble in water, 
absolute alcohol, and other neutral solvents, e. g., zein, corn; 
gliadin, wheat; hordein, barley. 

Gluten, readily obtained from wheat flour by washing 
away the starch, albumin, etc., is a mixture of members of 
the last two classes of proteins, glutenin and gliadin. 

(e) Albuminoids. — Simple proteins possessing a similar 
structure to those already mentioned, but characterized by a 
pronounced insolubility in all neutral solvents. The pro- 
teins concerned in the framework of the body are the most 
important members of this group, e. g., elastin and collagen; 
connective tissue; keratin — hair, nails and horn; and fibroin 
from silk. Acids or prolonged boiling with water convert 
collagen into gelatin. Gelatin is not, however, classed as 
an albuminoid. The English nomenclature aptly designates 
the albuminoids as scleroproteins. 

(/) Histones. — Soluble in water and insoluble in very dilute 
ammonia and, in the absence of ammonium salts, insoluble 
even in excess of ammonia; yield precipitates with solutions 
of other proteins and a coagulum on heating which is easily 
soluble in very dilute acids. On hydrolysis they yield a 
large number of amino-acids among which the basic ones 
predominate. In short, histones are basic proteins which 
stand between protamines and true proteins, e. g., globin, 
one of the constituents of hemoglobin ; thymus histone and 
scrombrone from sperm. 

(g) Protamines. — Simpler polypeptides than the proteins 
included in the preceding groups. They are soluble in water, 
uncoagulable by heat, have the property of precipitating 
aqueous solutions of other proteins, possess strong basic 
properties and form stable salts with strong mineral acids. 
They yield comparatively few amino-acids, among which 
the basic amino-acids predominate. These proteins are 
obtained from spermatozoa in which they occur in combi- 
nation with nucleic acid. The various members of this 
class are designated according to the animal from which they 
are obtained, as salmin from the salmon sperm; sturin from 
mackerel sperm, etc. 



168 PROTEIN FOODS 

II. Conjugated Proteins. — Substances which contain the 
protein molecule united to some other molecule or molecules 
otherwise than as a salt. 

(a) Nucleo proteins. — Compounds of one or more protein 
molecules with nucleic acid. This type of protein is the 
principal constituent of cell nuclei and is found in practically 
all protein-rich foods. Milk and the white of egg are im- 
portant exceptions. Nucleoprotein is a very complex sub- 
stance yielding upon hydrolysis first protein and nuclein. 
Nuclein then disintegrates into a second protein, usually 
basic, as histone or protamine, and nucleic acid. Nucleic 
acid may consist of one or more combinations of phosphoric 
acid, carbohydrate, and one of the purine or pyrimidine 
bases called nucleotids. Upon hydrolysis of a combination 
of nucleotids, the various nucleotids result. The phosphoric 
acid is next split off from the nucleotids leaving the purine- 
or pyrimidine-carbohydrate complex, nucleosid, which finally 
yields carbohydrate and the base. The following scheme 
shows the disintegration of nucleoprotein : 

Nucleoprotein 
/\ 
/ \ . 
protein nuclein 
/\ 

/ \ ; . 

protein nucleic acid 

(nucleotids) 
/\ 
/ \ 
phosphoric acid nucleosid 
/\ 
/ \ 
carbohydrate purine base 

pyrimidine base 

The purine bases from nucleoprotein are the chief source of 
the uric acid which appears in the urine of mammals. 

(b) Glycoproteins. — Compounds of the protein molecule 
with a substance or substances containing a carbohydrate 
group other than a nucleic acid, e. g., mucins and mucoids 
(osseomucoid from bone, tendomucoid from tendon, ich- 
thulin from carp eggs, helicoprotein from snail). 

(c) Phosphoproteins. — Compounds of the protein mole- 
cule with some, as yet undefined, phosphorus-containing 
substances other than a nucleic acid or lecithin, e. g., casein 
from milk, ovovitellin from egg yolk. 

(d) Hemoglobins. — Compounds of the protein molecule 
with hematin, or some similar substance, e. g., hemoglobin 
from red blood cells, hemocyanin from blood of inverte- 
brates. 



PROTEIN CLASSIFICATION 169 

(e) Leciiho proteins. — Compounds of the protein molecule 
with lecithin. 

III. Derived Proteins. — A. Primary Proteins Derivatives. — 
Derivatives of the protein molecule apparently formed 
through hydrolytic changes which involve only slight alter- 
ation of the protein molecule. 

(a) Proteins. — Insoluble products which apparently result 
from the incipient action of water, very dilute acids or enzy- 
mes, e. g., myosan from myosin, edestan from edestin. 

(b) Metaproteins. — Products of the further action of acids 
and alkalies whereby the molecule is so far altered as to form 
products soluble in very weak acids and alkalies but insoluble 
in neutral fluids, e. g., acid metaprotein (acid albuminate), 
alkali metaprotein (alkali albuminate). 

(c) Coagulated Proteins. — Insoluble products which result 
from (i) the action of heat on their solutions, or (2) the ac- 
tion of alcohol on the protein. 

B. Secondary Protein Derivatives. — Products of the fur- 
ther hydrolytic cleavage of the protein molecule. 

(a) Proteoses. — Soluble in water, non-coagulable by heat, 
and precipitated by saturating their solutions with ammo- 
nium — or zinc sulphate, e. g., protoproteose, deuteroproteose. 

(b) Peptones. — Soluble in water, non-coagulable by heat, 
but not precipitated by saturating their solutions with 
ammonium sulphate, e. g., antipeptone, amphopeptone. 

(c) Peptides. — Definitely characterized combinations of 
two or more amino-acids, the carboxyl group of one being 
united with the amino group of the other with the elimination 
of a molecule of water, e. g., dipeptides, tripeptides, tetra- 
peptides, pentapeptides. 

Influence of Heat. — The effect of heat upon simple pro- 
teins is to cause them to coagulate. Such changes are con- 
tinually occurring in the preparation of food for the table. 
The boiling of an egg, or the roasting of meat is accompanied 
by the coagulation of the protein, and it is to a large extent 
the coagulation of the protein among expanded gas bubbles 
which keeps bread and cake " light." Two changes take 
place in the coagulation of protein: there is first a reaction 
between the hot water and the protein as the result of which 
the protein loses certain of its characteristic properties, such 
as solubility, i. e., the protein is denatured. Secondly, the 
altered particles of protein agglutinate into visible masses 
or coagula which separate from the solution. When the 
protein is held in the meshes of connective tissue, etc., the 
denatured protein shrinks or contracts so that water and 
dissolved salts are squeezed out. This phenomenon is 



170 PROTEIN FOODS 

called syneresis. The accumulation of beef juice around a 
roast when cut on the platter is the result of syneresis. The 
presence of acid and small quantities of salt facilitates the 
coagulation of protein. An excess of acid or alkali results 
in a solution of the protein and prevents coagulation. 

Certain proteins of the albuminoid class, such as collagen, 
are readily hydrolyzed (rendered soluble) particularly so in 
the presence of small quantities of acid. The long-continued 
cooking (usually just below the boiling point) of tough cuts 
of meat accomplishes the hydrolysis of the connective tissue 
(rich in collagen) which tends to free the muscle fibers and 
permit their ready separation, i. e., makes the meat tender. 
The use of veal for soup stock and the ease with which the 
fibers of fish are separated is due to the large proportion of 
easily hydrolyzed connective tissue which they contain. 
Acid facilitates hydrolysis; it also tends to cause protein 
material to swell. The value of acid in cooking fish and 
tough meat is, then, self-evident. 

Protein combines with both acid radicles and basic radicles 
to form protein salts ; the insoluble curd formed in the coagu- 
lation of milk occurs because the calcium salt of casein is 
insoluble in water; the sodium or potassium salts are soluble, 
and it is in this form that certain soluble casein preparations 
are placed on the market. Certain proteins of the legumes 
form insoluble calcium and magnesium salts, which is the 
reason for the objection to the use of hard water in prepar- 
ing legumes for the table. The use of egg white, etc., as an 
antidote for poisons is due to the insoluble salts which are 
formed by the protein with the heavy metals. 

Effect of Low Temperatures. — Low temperatures have no 
direct effect upon protein. Its properties may be altered, 
however, as the result of changes produced in. the medium in 
which it is suspended. The crystallization of the intracellu- 
lar water results in a concentration of the salts. This causes 
the precipitation of some proteins and the solution of others. 
Upon the return to the normal temperature the original 
state is restored. Long-continued low temperatures pro- 
duce a change in the precipitated proteins so that they will 
not redissolve. The change just noted has been shown to 
occur in plants. 

During refrigeration protein food-stuffs undergo consider- 
able modification as the result of predominant enzyme ac- 
tion, autolysis, rather than of bacterial action which shares 
in the transformation at room and body temperatures. 
Low temperatures inhibit both bacterial and enzyme action, 
the former more than the latter, however. The changes 



EFFECT OF LOW TEMPERATURES 171 

which occur at low temperatures are analogous to those 
which take place in aseptic or sterile tissues, either in the 
body or out of it. The "ripening" of flesh is due to these 
autolytic changes brought about by the intracellular en- 
zymes. The action of the intracellular proteases is quite 
similar to that of the digestive enzymes, particularly trypsin. 
Protein passes gradually through the various stages of pro- 
teolytic digestion, finally yielding amino-acids. Examination 
of refrigerated meat, for instance, shows an increase in the 
quantity of water-soluble proteins, indicating a partial 
digestion. Other enzymes produce changes in the fats and 
carbohydrate. The changes which result in foods preserved 
with certain chemical substances, without the use of heat, 
are the result of autolysis. 

Bacterial growth is not entirely checked at comparatively 
low temperatures and changes undoubtedly occur as the 
result of their action. At higher temperatures, room tem- 
peratures and above, the activities of bacteria increase. The 
products of their action on proteins are in part similar to 
those produced in enzymatic digestion. The harmful effects 
of bacteria from a dietary point of view are not in the bac- 
teria themselves so much as in the products (ptomaines) 
produced in the food, protein, during their growth. These 
substances are produced by non-pathogenic as well as by 
pathogenic organisms. The ptomaines are soluble basic 
substances closely related to the amino-acids; not all are 
toxic. 

The changes which proteins undergo in the course of diges- 
tion and absorption have already been discussed (p. 38). 
The rate with which they are made available for absorption 
depends upon their physical properties, whether they are 
in solution or solid, dense or finely divided, will imbibe 
water easily or with difficulty; and upon their chemical 
properties, such as acidic or basic, complex or simple. Pre- 
paration of food for use is often accompanied by change in 
the digestibility as well as in the availability of the food- 
stuffs. This is particularly true with regard to protein. 
The total available quantity of the protein is often increased 
in the course of preparation. The effect of grinding vege- 
table food-stuffs very fine is to increase their total digesti- 
bility. The influence of heat upon the connective tissue of 
animal food-stuff is to cause a partial conversion of collagen 
into glatin ; hence the ease of digestion is increased. In vege- 
table food-stuffs the indigestible cellulose structure is rup- 
tured through the combined action of heat and water, thus 
promoting the action of the digestive enzymes upon the con- 
tained protein and carbohydrates. 



CHAPTER IX 

MEAT OR FLESH FOOD 

The dietary value of meat is due chiefly to its protein 
content. It contains in addition a varying quantity of lipin 
or fat, a small amount of carbohydrate, salts, and certain 
nitrogenous derivatives related to the proteins called ex- 
tractives. The palatability, variety, ease with which the 
flavor may be modified, facility of preparation, concentra- 
tion of protein, and digestibility are factors which have made 
meat the most important protein of the adult human dietary. 
With regard to its biological value meat contains adequate 
protein and the water-soluble and anti-scorbutic vitamines. 
It is relatively poor in the fat-soluble vitamine, calcium, 
sodium and chlorine. The use of meat in the diet, therefore, 
requires the correction of these deficiencies through the use 
of vegetables, particularly the leafy vegetables. Cereals, 
grains and seeds will not serve to correct the deficiencies of 
meat. 

The dietary and economic advantages and disadvantages 
of animal and vegetable protein have been discussed (p. 144). 

Meat is derived almost entirely from the skeletal or striated 
muscles. Such muscles are composed of fibrils enclosed in 
sheaths known as sarcolemma (fibers) and bound together 
in the form of bundles by connective tissue. The fibers 
terminate in bundles of white fibrous connective tissue, the 
tendons, by means of which they are attached to the bones. 
Embedded in the connective tissue of the muscle bundles 
are cells more or less rich in fat, while between the various 
muscles comparatively large masses of fatty tissues are 
found. Living muscle is practically neutral in reaction, 
but after death lactic acid is formed and the reaction rapidly 
changes to acid. An alkaline reaction in meat is an indica- 
tion of putrefaction. 

The important proteins of muscle plasma are myogen (a 
globulin) which predominates, and myosin. After death 
these proteins become coagulated to form the muscle clot; 1 
this is the form in which the greater portion of the protein 
of meat exists. Immediately after death autolytic changes 
commence with the formation of lactic acid and protein di- 

1 Myosin is the name given to muscle clot by some investigators. 



MEAT OR FLESH FOOD 173 

gestion products and are attended by an increase in the 
quantity of soluble proteins. These are the processes con- 
cerned in "ripening." 

The connective tissue contains a large percentage of the 
albuminoid collagen, which is a source of gelatin — the base 
of the jelly of cooked meat. The flesh of young animals, e. g., 
veal and lamb, is particularly rich in connective tissue and 
their bones in collagen. The readiness with which meat 
from such animals yields gelatin makes it valuable as the^. 
basis of soup. Fish are also rich in gelatin-yielding tissues. 
Blood remaining in the capillaries and bloodvessels and in 
the blood plasma surrounding the cells, contains serum 
albumin, globulin, fibrin, etc. 

The hemoglobin in muscle and the residual blood give 
meat its red color. The identity of the coloring substance 
in blood and in muscle is not generally admitted, although 
the close relation is acknowledged. The quantity of hemo- 
globin varies; it is greatest in muscles concerned in long- 
continued and powerful contractions and least in the more 
passive muscles. The dark and light meat of the birds 
show this relation. Certain species, e. g., the rabbit, are 
poor in hemoglobin. The muscle of the young of most 
species is low in hemoglobin, hence their light color. The 
decided red color of meat preserved with nitrates appears to 
be due to the presence of nitrous oxide hemoglobin. 

The small amount of glycogen normally present in muscle 
is almost entirely changed to glucose after death. The com- 
paratively large quantity of glycogen in fresh horse meat is 
one of its distinguishing characteristics. Fat varies in quan- 
tity kind, and color with the condition of the animal, the 
food ingested, and the cut (portion of the carcass). 

Flavor in meat is due to the presence of the extractives — 
substances soluble in water, alcohol, or ether. In addition 
to the carbohydrates and fat just mentioned these include 
certain non-protein nitrogenous constituents, such as creatin, 
xanthin, hypoxanthin, inosin, etc.; the latter are the chief 
source of the exogenous uric acid. It is the latter extrac- 
tives which the gouty patient should avoid and to which 
vegetarians and certain food cults object, holding them to 
be waste products and a burden to the excretory system. 

The presence of purine compounds in the diet under cer- 
tain pathological conditions, such as gout, is objectionable. 
It is important to know, therefore, the relative quantity of 
these substances in various foods. A table giving the purine 
contents of various kinds of flesh and of certain other foods 
will be found in a subsequent discussion of diet in disease. 



174 



MEAT OR FLESH FOOD 



Meat often contains certain substances characteristic of 
the food ingested which give to it the flavor so prized by 
epicures: these are particularly evident in game. 

Flesh or meat is ordinarily composed of about three-fourths 
water, but there is less water in fat than in lean meat and 
likewise in old than in young animals. In the ash of muscle 
the salts of potassium and phosphoric acid predominate. 
Traces of sodium, calcium, magnesium, iron, sulphur, and 
chlorine are also found. The following table gives the 
approximate proportions in which the inorganic constituents 
occur in meat. 

Composition of the Ash of Typical Flesh Foods. 



Beef, lean . 
Veal, lean . 
Lamb, me- 
ium fat . 
Pork, lean . 
Poultry 
Fish . . 

z 

< 

PER jf 

CF-NT 


CaO. 
O.OII 
0. 16 

o . 0039 

O.OI2 
O.OI5 
0.03 

U.W) 


MgO. K 2 0. Na 2 0. 

. 04 . 42 . 09 

O.O45 O.46 0.12 

O.04 O.29 O.093 
O.O46 O.34 O.I3 
O.06 O.56 O.13 
O.O4 O.4O I.30 

u 

"< 

J = 
a. ec 


P 2 O . 
O.50 
O.50 

O.42 

0.45 
O.58 
O.4O 

z 
3 


CI. s. 
0.05 0.20 
0.07 0.23 

0.12 0.23 
0.05 0.20 
0.06 0.216 

2.4O 0.22 

f 

3 
O 
(X 


0. 

0. 

•*. 


D 
I 
O 


Fe. 
OO38 

OOO3 

PER 
CENT 


70 
60 
60 

<o 




















I 
















\ 

\ 
\ 
















\ 
















\ 

\ 




/ 
/ 
/ 
/ 


X 
X 
X 
X 
X 
X 






. 






SO 




A 


\ 

\ 


\ / 
'/ 

/ \ 
/ 






N 
X 
N 
X 
X 
X 








/ 


\ 
\ 

V 


/ 
/ 


' 




"> 






IO 




*'•». 












"*■ 


















VISIBLE TAT 






























1 1 







Fig. 3. — Percentages of lean, visible fat and bone in the straight wholesale cuts. 1 
(Courtesy of the Illinois Agricultural Experiment Station.) 

Some meats when purchased contain inedible parts, such 
as bone, the exterior portions of the carcass, large blood- 
vessels, connective tissue, gristle and tendon. In consider- 

: Hall and Emmett: Univ. 111. Agr. Exp. Sta., Bull. 158, 1912. 



COMPOSITION OF MEAT 



175 



ing a particular piece of meat from a purely dietary point of 
view allowance should be made in the calculation for the 
waste which these portions represent. From an economic 
standpoint it is essential to know the quantity of edible 
material likely to be derived from a given piece of meat. 
Fig. 3 gives the percentages of lean, visible fat, and bone in 
the straight wholesale cuts of beef. 

An inspection of this chart reveals in general an inverse 
relation between the percentage of lean meat and that of 
visible fat; the relative weight of bone is more variable. 

The proportions of the various food-stuffs in meat varies 
according to the kind of animal and the portion of the anat- 
omy from which it is obtained. The same "cut" of meat 
from different animals varies according to its age and nutri- 
tive condition. The relative differences in the protein 
content of the various cuts of beef is shown in the following 
chart (Fig. 4) prepared by Hall and Emmett, which gives 
the percentage of the total protein in the boneless meat of 
wholesale cuts. 



PER 
CENT 



if 

TV) 


























































































































































































_--- 











» — - "* 








"■■"■■ 


















_ .... ... 






















TOTAL PRO 










1 


















1 















A 

CENT 

7 



13 



Fig. 4. — Percentages of total and soluble protein in the boneless meat of the 
wholesale cuts. 1 (Courtesy of the Illinois Agricultural Experiment Station.) 

The curves show a relative increase in the quantity of pro- 
tein as we consider the cuts from the left to right. Calcu- 
lated on the basis of the dry, moisture-free, substance an 

!Hall and Emmett: Univ. 111. Agr. Exp. Sta., Bull. 158, 1912. 



176 



MEAT OR FLESH FOOD 



even greater increase is found, because the cuts on the right 
contain more lean and less fat and also because the lean 
meat has a greater water content. When the fat is excluded 
from consideration, the protein content of the various cuts 
is quite similar. In other words, the difference in the various 
cuts of beef is due to the varying quantities of fat and water. 






H/ND QUARTER 




Round 




Rump 


1 £ 


I Pump 




Round: rump & shank oft 


£. Round steak, first cut. 




3-/J Round steaks. 


14 Pound steak, /as/ cut. 




J 5 Knuck/e soup bone 




16 Pot roast 




Hind shank. 




17, /8 Soup bones 




19 Hock soup bom 




Loin 




1 BufT-end sir/oin steak. 




£ Wedge- bone s/'rfo/n steak. 




3,4 Pound -bone 


^ 


5,6 Doubte-bone 




7 Hip-bone 


£ 


Q H/p-bone Porterhouse steak. 
9-J5 Kecfulqr 


* 


>i 


16-18 Club steaks. 


k. 


Flank 




/ Ftank steak 




£ 3tew. 





rORE QUARTER 


R/s 




J 


IJtb & IZtb R/b roast 


L. 


3tt> 3 tOit> " - 


3 


jib £ Qih 


4 


Qih - 


Chuck 




1 


3tt> R/b roast-. 


£-9 


Chuck steaks 


10 -D Pot roasts. 


14- 


Clod 


15 


Neck 


Plate 




1 


brisket 


t 


Navel 


3>4- 


R/b ends 


Fore sham* 


/ 


3tew. 


a 


Hnuckfe. soup Aon*. 


3-6' 


3oup bones. 



RETAIL • CUT5 ■ OF - BEEF 



Fig. 5. — Method of cutting the three sides, showing retail cuts. (Courtesy of 
the Illinois Agricultural Experiment Station.) 



COMPOSITION OF MEAT 



177 



Composition of Typical Flesh Foods. 1 







Protein 










Water, 


NX6.25, 


Fat, 


Ash, 


Fuel value 




per cent. 


per cent. 


per cent. 


per cent. 


per pound. 


Beef . . . 


. 70.O 


21.3 


7-9 


I. I 


709 


Veal . . . 


. . 70.3 


21.2 


8.0 


I.O 


711 


Lamb . 


. . 63.9 


19.2 


16.5 


I . I 


I022 


Pork . . . 


. 60 . 


25.O 


14.4 


1-3 


IO42 


Poultry 


• • 63.7. 


19 -3 


16.3 


1.0 


IOI6 


Fish . . . 


. . 81.7 


17.2 


0.3 


1.2 


324 



nso 


uble. 


Total. 


15-56 


16.98 


14 


88 


16.69 


14 


42 


16.50 


14 


67 


16.26 


13 


94 


15-59 


13 


40 


14.87 


II 


59 


12.96 


II 


30 


12.56 


II 


12 


12.32 


9 


76 


10.59 


eS 


78 


9 44 



The differences among the percentages of the food-stuffs in 
the various kinds of meat are likewise due to similar varia- 
tions; this is shown in the accompanying table taken from a 
compilation of analyses by Atw r ater and Bryant. 

Percentages of Water-soluble, Insoluble, and Total Protein in 
the Boneless Meat of the Wholesale Cuts. 1 

Wholesale cuts. Soluble. 

Fore shank 1 .42 

Clod 1. 81 

Round 2.08 

Hind shank 1 .59 

Neck 1 . 65 

Chuck 1.47 

Loin 1.37 

Rump 1.26 

Rib 1 . 20 

Plate 0.83 

Flank 0.66 

Fig. 5 p. 176 enables one to locate the portion of the animal 
under consideration. 

Effect of Heat on Meat. — Cooking. — The objects to be 
accomplished by cooking meat are the improvement of its 
flavor and appearance; the modification of its texture, and 
the destruction of parasites and bacteria. Digestibility of 
protein is not increased by cooking; it is diminished in many 
cases. Such changes as the hydrolysis of connective tissue 
and comminution increase the ease of digestion. 

The flavor acquired by meat through cooking is due to 
changes, probably oxidative, in the soluble, extractive, por- 
tions of the flesh and in the fats. 2 A study of the develop- 
ment of flavor in which the juices were separated from the 
insoluble portions (fiber) of beef showed the flavors to develop 
in the juice more than in the residue, and in the extract not 
coagulable by heat more than in the coagulable portion. 
A study of the effect of various temperatures show r ed the 
flavor to develop most at temperatures above ioo° C; be- 
low this the taste is more or less insipid. The pronounced 
flavors developed by dry heat are thought to be due to the 

1 Hall and Emmett: Univ. 111. Agr. Exp. Sta., Bull. 158, 1912. 
2 Grindley and Emmett: U. S. Dept. Agr., Office Exp. Sta., Bull. 162. 

12 



178 MEAT OR FLESH FOOD 

higher temperatures attained. The fat of meat when heated 
sufficiently high also gives rise to characteristic flavors. 

The appearance of meat is improved by cooking as the 
result of the coagulation of the proteins and the transforma- 
tions in the hemoglobin whereby the more or less objection- 
able reddish-purple color of uncooked, raw meat is changed 
to the light red or brown color of cooked meat. These 
changes in appearance are most evident in roast beef and 
are enhanced by the crisp outer layer of fat. 

Three methods are employed to make a piece of meat ten- 
der: (i) Cooking for a long time at low temperature; sim- 
mering at approximately 8o° C. (this is sometimes incorrect- 
ly designated boiling) whereby the insoluble collagen of the 
connective tissue is changed to gelatin, thus loosening the 
fibers. (2) The mechanical separation of the fiber from the 
connective tissue by scraping, a tedious process practised in 
the preparation of a readily digestible protein food for the 
sick. (3) Grinding, mincing, or pounding by which means 
the connective tissue is mechanically severed. 

In the cooking of meat two general methods are employed 
which differ in the mode of application of the heat: (a) The 
direct application of radiant heat, as in roasting and broiling 
and (b) the application of heat through the medium of a 
liquid, as boiling in water and frying in deep fat. 

Roasting and baking are used synonymously by the aver- 
age cook. A distinction should be made, however, between 
so-called roasting or baking and true roasting. 1 True roasting 
is cooking by radiated heat from glowing coals, but one side 
of the food being exposed to the heat at a time. Broiling is 
essentially the same in principle as true roasting, but the 
food is brought into direct contact with radiant heat. The 
length of time of the two processes differs for a thinner cut of 
meat is used for broiling. Baking is cooking in a ventilated 
oven. Although frying in deep fat belongs properly, as indi- 
cated, to the indirect method of cooking, the results obtained 
are more like those obtained with the direct application of 
dry heat. 

The changes produced in meat by cooking, aside from slight 
differences in flavor, are of two kinds, those characteristic of 
roasting and of boiling. Combinations of these, as in pot 
roasting, so admirably adapted to the preparation of tough 
cheap cuts, yield some of the advantages of each method. 
In this case the tenderness of boiled meat is combined with 
the flavor of roasted meat. Grindley and Emmett have 

Sevier and Sprague: Univ. 111. Agr. Exp. Sta., Circular 71, 1903. 



EFFECT OF HEAT 179 

shown the effect of roasting (baking) to be similar to that 
produced in broiling, parboiling, sauteing, and frying. 

Roasting is practised principally for the development of 
flavor and appearance. The application of a high heat sears 
the surface of meat and immediately coagulates the pro- 
teins, the hemoglobin being changed from bluish red to brown. 
Such treatment also causes changes in the surface fat, thus 
developing an additional flavor. The preliminary searing, 
usually conducted at a higher temperature than the subse- 
quent cooking, serves to retain the water and the extractives. 
The subsequent changes which occur within the roast are 
gradual for muscle fibers are very poor conductors of heat, 
and the internal temperatures never reach those of the air 
surrounding the meat. 

Precise Method of Roasting Beef. — As the heat gradually 
penetrates inward the proteins are coagulated at a low heat, 
and the hemoglobin is changed in color, assuming first the 
pink color characteristic of rare meat, and finally becomes 
brownish gray — "well done. " This last color is common to all 
meats heated to a temperature above jo° to 75 C. and is due 
to the complete coagulation of the hemoglobin. At these 
higher temperatures the coagulated protein, and conse- 
quently the piece of meat shrinks. Careful studies of the 
physical changes occurring during roasting have emphasized 
these points and established the conditions necessary to ob- 
tain the desired kind of roast — rare, medium, or "well done" 
(Sprague and Grindley). The inner temperature of the 
meat determines the degree of the roast regardless of the 
external temperature. When a thermometer placed in the 
middle of a roast registers a temperature of approximately 
43°C., 55° C, or 70 C, if the roast be removed from the 
oven, the final temperature will be approximately 55 C, 
65 C, or 70 C, and the meat will be respectively rare, 
medium, or well done. These temperatures hold with the 
external temperature of the average roasting oven (175 to 
^S C.). At lower oven temperatures the temperature at 
which the meat is removed will more nearly approximate the 
final one desired. 

The most desirable conditions for successful "boiling" of 
meat are long continued heating at a temperature below the 
boiling-point, 8o° to 85 C. Under such circumstances the 
connective tissue is softened and the protein coagulated with- 
out becoming hardened (toughened) characterized by the 
shrinking of the meat. Long experience in cooking has de- 
monstrated the advisability of searing the outside of the 
meat or plunging it into boiling water and keeping it at this 



180 MEAT OR FLESH FOOD 

temperature for a few minutes before beginning the cooking 
at the lower temperature. Such a practise is held to assist 
in the formation of a more or less impervious layer by the 
coagulation of the surface proteins which retains the ex- 
tractives and soluble proteins, and thereby improves the 
nutritive value and flavor. If a rich broth is desired the 
opposite method is used, beginning with cold water which is 
gradually heated. The work of Grindley and his associates, 
studies on the losses in cooking meat (see below for further 
discussion), has shown, however, that when meat is cooked 
at 8o° to 85 C. there is practically no difference in the quan- 
tity of nutrients (protein, extractives, and ash) which pass 
into the broth when the cooking is begun in hot or cold water. 
The length of time and the fat content have a much greater 
effect upon the losses than the method of cooking. 

Chemical Changes in Meat as the Result of Cooking. — The 
chemical changes which occur in meat during cooking, 
whether by roasting or boiling, consist in an increase of in- 
soluble (coagulated) protein and in the removal of water 
and extractives (nitrogenous, non-nitrogenous, fat and ash). 
Boiling causes a removal of a greater proportion of these sub- 
stances than does roasting. Fat meats lose less water, pro- 
tein, and mineral matter, but more fat, than do the lean 
cuts. Prolonged cooking at higher temperatures is accom- 
panied by greater losses than at lower temperatures. Under 
like conditions the larger the piece of meat the smaller are 
the relative losses. As already mentioned, when "boiling" 
at 8o° to 85 C, the effect of such preliminary treatment, as 
placing in cold or hot water has little effect upon the quantity 
of material found in the broth. It is interesting to note that 
the beef used in the preparation of beef tea or broth loses 
little of its nutritive value, although it loses much of its 
flavoring material. The work of Grindley and his associates 
has been verified and extended by that of other investigators, 
particularly with regard to the changes in the protein and 
extractives under various conditions. The table on page 
181 taken from their results shows the influence of cooking 
upon the composition of meat. 

Digestibility of Meat. — Many conflicting statements are 
made with regard to the digestibility of meats of various 
kinds and as prepared by the various methods of cooking. 
The observations upon which the conclusions regarding the 
digestibility of meat are commonly based are of two general 
types (1) the time the food remains in the stomach and (2) 
the degree of digestion, i. e., the amount absorbed, measured 
by the quantity of nitrogenous substances excreted in the 
feces. 






EFFECT OF HEAT 



181 



^ 


O •-< ^ 






d 


M fOH 






o 
H 


CO lO ■<*■ 






<y i.5 


lO On CO 






60 S u 


CO >-. -rt- 






o ° -s 








-SZ2 


6 6 6 


H 




g G 








_c 


lO CN Tt" 


§ 




"3 


00 h N 


Q 




o 


CN lO CO 


W 




£ 




O 






conO "*h 


o 
u 


i-i 00 


.c 


OvO N 


NO NO 


< 


H-i 6 M 


p 

fa 
o 


d m 




lO ^vo 




^r^ 




On CO On 


H 


CN 00 






X 




rt 


O OnO 


o 


HH VO 


fe 


COO 






"3 


NfOO 







00 *-» 00 

'•g g s 



00 O lO 
O NO to 



r^r*- 


in 
X 
H 


o no 


1 1-1 


O 


1 


m 




o 




£ 


CO CM 


<5 


00 O 


CO 


O On 

1 1 


H 
U 



CO ION fD 



0* O O 
tJ- CO ON 



Tj- ON Tt- 

^t" CO ON 



NO iO 

O NO 00 



HH HS O O HI O O 



£ £ 



00 On co 



H 



s 

W (ON 
H vo 00 

fc O co 

M I + 

Q 
W 

oo 
m 
W 
P* 

Ph • • 

X • • 
w 

o 
z 

w : : 
o . . 
o 
u 



o o o 



<u 



x 



c: C o q 

£U<PQP< 
PQ 



bio.5 

.s-a 

o q 







<N 




00 HH 


NO OvO h 




N 1-H 


lO OOVO N 




On On On On On On 




Bg 






3 3 


•^o . . • 


o 


.§£ 


0) 

u 

. O) . . . 




B B 


5 s 




Average 
roth, clear 
Maximum 
Minimum 
Average 


3ld-wa 

Fresh 

roth: 

Comp 

Comp 


CJ PQ 




PQ 



182 MEAT OR FLESH, FOOD 

The first method is open to the objection that it measures 
the activity of the stomach and tells nothing of the processes 
which go on in the intestines. Stomachic processes involve 
chiefly the swelling of the protein under the influence of the 
hydrochloric acid and a partial hydrolysis by the pepsin, 
resulting in the reduction of the food to a semifluid mass, but 
there is little absorption through the gastric mucosa. More- 
over, so. many variables must be taken into consideration 
accurately to measure the time required for food to leave the 
stomach that the results obtained by such experiments must, 
unless they are very striking, be considered as merely sugges- 
tive. For example, the ease of swelling and the degree of 
peptic activity are modified by the mode of preparation. 
Fat particularly tends to retard gastric digestion; there is no 
lipolytic activity of importance in the stomach. The com- 
position of the flesh likewise affects gastric digestion, very 
fat meats being less digestible than lean meats. The pres- 
ence of large quantities of connective tissue, particularly in 
partially cooked food, serves to hinder peptonization. Finely 
divided meat is more easily attacked by the gastric juice 
than large masses. Foods which are acid remain a shorter 
time in the stomach than do alkaline foods. The quantity, 
strength, and acidity of the gastr*ic juice have a very pro- 
nounced effect upon the rate of ejection from the stomach. 

The second method of measuring digestibility — the com- 
pleteness of absorption of the ingested food — indicates only 
the extent of absorption and does not enable us to judge of 
the length of time required for its digestion. Food which is 
completely absorbed leaves little residue and is likely to lead 
to constipation, while that which is poorly absorbed may 
(a) be subject to extensive bacterial action in the large intes- 
tine, (b) increase the rate of peristalsis, or (c) lead to the 
accumulation of large masses of food residues in the intes- 
tines. In a well-selected diet, foods which are completely 
digested are accompanied by some of those which are difficult 
of digestion, particularly foods low in protein and rich in 
cellulose, such as vegetables and fruits. In the treatment of 
pathological cases it is particularly necessary to take into 
consideration the degree of digestibility of the foods pre- 
scribed. The extent to which a food is absorbed depends 
quite as much upon the nature of food as does the ease of 
digestion. Foods that contain material in quantity which is 
not acted upon by the digestive enzymes are not only poorly 
absorbed but retard the digestion and absorption of other 
foods which are ordinarily completely digested and absorbed. 
The mode of preparation also influences the extent of ab- 



MEA T PREPARA TIONS 183 

sorption, for by its proper preparation connective tissue and 
cellulose structures are partially or completely hydrolyzed 
or disintegrated and thus become more readily and com- 
pletely digested. 

Conventional consideration of the relative digestibilities of 
various kinds of meat is based, then, upon data which 
are not entirely satisfactory. Clinical observation is an aid 
in determining the digestibility of food in its most general 
sense, but here there may be influences of personal idiosyn- 
crasies as the result of pathological conditions in the patient 
under observation, and this is particularly true of protein 
foods. Some individuals show distinct reactions to certain 
foods. Many cases are known, however, in which the ina- 
bility to eat eggs, fish or milk is a psychical factor and that 
the ingestion of such foods is not attended by metabolic 
disturbances. 

In feeding persons whose condition necessitates prompt 
emptying of the stomach, food must be selected which will 
pass out readily, just as in certain intestinal diseases food 
must be taken in such a form that complete absorption 
occurs without extensive intestinal digestion or in which 
little residue results. These factors are discussed on p. 52. 
It seems to us that the method of the preparation and the 
consistency of the food are more important factors in the 
treatment of nutritional diseases in which a specific food 
substance is not involved, such as a specific idiosyncrasy 
or disease, than the selection of a few from among a number 
of foods compatible with the patient. 

MEAT PREPARATIONS 

Certain products prepared from meat, particularly from 
beef flesh, such as digested beef, beef juice, beef broth, beef 
extracts, and gelatin, contain less insoluble material than 
meat itself and are therefore held to be desirable not only 
for general use but for use in the sick-room and for convales- 
cents. Such products are either readily soluble in water or 
yield fine aqueous suspensions. It is the possibility of 
furnishing protein or its digestion products in a fluid or soluble 
form which makes these preparations attractive for the 
special diets of therapeutics. 

The nutritive value of meat preparations as compared 
with meat depends upon the mode of preparation. They 
are prepared from lean meat through the action of digestive 
enzymes, with the aid of heat, or by simple water extraction. 
Beef extract and some beef broths contain only small pro- 



184 



MEAT OR FLESH FOOD 







.3 




















co 

ra 
o 


8 


s 


o 

CM 


o 


CO 










t- 


iO 


in 


o 


o 










PL, 


















i O 




















^3_H cj 


o 


o 


o 














o 




fc- 


o 


"* 










m 


CM 


CM 


o 


rH 








si 




















< 


3 






















§ 


ti 


O 
OS 


s 


8 












r-l 


CD 


o 


© 


o 










U 




















13 


O 

CO 


a 
co 


g 


CO 

co 


o 


§ 


CO 


Q 




H 


r-l 


CM 


3 


© 


CO 


1-1 


o 


o 






^ 






















-o.S 
c S 


s 


09 

d 


o 

CM 


CM 

6 


N 

d 












a3 

_3 

3 




















0) 


6 


CO 

6 


CO 

6 


o 
6 


o 

o 










to 


Ph 




















CD 




















CU 






















o 

co 


$ 


CO 

r-l 


CM 
O 


CJ 












CU 


r-H 


o 


o 


O 


H 












O 






















_3 

8.5 


S 


9 


8 


CM 
O 


o 

o 












o 


o 


o 


O 


o 








s 




u 












9 

CO 

d 


S3 

d 


in 

CO 

d 


M 
O 


6 














+J co 3 


3 


Cft 


OS 




01 










i_l TO CU 
r^fc! 


*tf 


r-l 


r-l 


O 


o 








O 


















CO 

£ 

l-c 

o 


T3 


















t>: 


















fe 


o <u 


,_, 


g 


o 


,_, 


o 










oS 


lO 


OS 


CO 


CM 










<# 


,_l 


O 


o 


01 






























Cu cu 




















: a 


















.2d 




















c Si 

SS 


00 


3 


co 

CM ' 




•* 










o 


O 


O 




o 










< fl 


















rotein 
coag- 
lable 
rogen) . 




© 






s 


s 


00 

m 


CO 
CO 






o 






o 


CM 


o 


o 




Ph^ 3 .^ 




















c 


















d 

*3 ^ 
TO M 

o2 




















r-l 


o 


CO 


g 


s 


O 
CM 


3 


CO 
CO 




OS 


n< 


CO 


o 


01 


CO 


o 


o 




3 




















CD 


m 


o 


t- 


co 


CM 


r-l 


CO 






TO 


8 


9 


s 


s 


l-l 


OS 

co 


m 
os 


5s 








2 




cu to 
















S 

CO 

o 
to 

I-. 


CU 

y 
"3 


a ^ • 

» CO 

3 

>>.2 


ID 
X> 

O 

a 


beef . 
broth: 
mplete 


CU 

cu 


1 




CO 

Bl 


cd 

CU 


12 to rt 

3 -u )-l 


cu 




£ 


1 






Ph 


W 


f^ 


PQ 


P* W 





0) a, 






£>. 
a -a 

W CU 

S"3 



cj P. 
O a. 



31 g 

M og 



O cu 3 

cu i> 
cox) %. 
° 3 9* 

o , 

&SJ8 



'3 Ih CU 

■g 3 

u ao 

- cu *> 
co „ O, 



jS £o 

•^^ o^3 
MX) o +j 

•cU^rH-O 

■ © . 41 

otjw a 

I-, 3 . cu 

a ., m- 
. -2<;2 



H M O © 

o o 

-« V S . 
S g 2 S 

^ fi ^c? 

§".?+} 

'3 3 "a c 

111° 

U(-wU | 



ME A T PREP A RA TIONS 185 

portions of nutritive protein material, whereas cold pressed 
beef juice, gelatin, and broths prepared with gelatin-yielding 
meats and flesh in which the proteins have been partially 
digested are highly nutritious. The table on page 184 gives 
the comparative composition of such products. 

Meat Extracts. — Beef extract, the most common meat 
extract, contains the water-soluble, non-coagulable substances 
in meat in a concentrated form. These consist essentially 
of non-protein, nitrogenous extractives such as creatine, 
purine bases, etc. ; non-coagulable products of protein hydro- 
lysis, amino-acids, proteoses, peptones, and gelatin, and the 
salts of muscle, a large proportion of which are salts of potas- 
sium and phosphoric acid; sodium chloride is sometimes 
added in the preparation of the extract. Extracts prepared 
from meat containing considerable quantities of connective 
tissue are more likely to contain greater quantities of gelatin. 
Gelatin, digested meat, and yeast extract are sometimes used 
as adulterants of meat extracts. Yeast extract is being used 
not only as an adulterant but also as a substitute for meat 
extract. 

Meat extracts are particularly valuable as stimulants, for 
their salt content, and as flavoring materials for otherwise 
unpalatable dishes. The extractives of meat have been 
shown to stimulate the flow of the gastric juice: in this way 
they tend to increase the digestibility of foods. Extracts 
to which have been added gelatin or finely divided protein — 
made more or less soluble by digestion or solution in acid — 
increase the food value of such preparations. The use of 
beef juice is, from a nutritive point of view, to be preferred 
to such preparations. 

Meat Juice. — Meat juice, particularly beef juice, is often 
prepared and used in the diet of the sick-room and for feed- 
ing infants. Such extracts are prepared by pressing out the 
water and soluble proteins from raw or half-broiled lean 
meat, preferably from finely divided meat. Preparations 
of this kind contain a certain proportion of the water soluble, 
coagulable proteins in addition to the ordinary extractives 
obtained by a method which involves heating to a tempera- 
ture above the coagulation temperature of protein. They 
have, therefore, considerable nutritive value and may be 
used for the administration of protein in a liquid form. 

Commercial preparations of meat juice can be obtained 
but they are never as satisfactory as the freshly prepared 
juice and broths. 

Meat Broths. — Meat broths are of two kinds: (a) those 
that have been prepared by boiling beef, mutton, veal, 



186 MEAT OR FLESH FOOD 

chicken, etc., with water and straining off the protein ma- 
terial; (b) those prepared by extracting the juice from finely 
hashed meat with a small quantity of cold water, and ex- 
pressing the water retained by the meat. The latter process 
removes a greater proportion of the soluble protein consti- 
tuents of the meat and is therefore more economical. The 
product is, of course, more dilute than in the case of meat 
juice, above, but the greater proportion of protein it contains 
makes the two products comparable. The composition ol 
the water extract varies of course with the quantity of water 
used. Such products contain from 2 to 5 per cent, of pro- 
tein and a fraction of 1 per cent, of fat. (See table, p. 181.) 
Meat broths, method (a), are similar to meat extracts except 
that they have not been concentrated. 

Beef tea is essentially beef broth which has been prepared 
according to the second method and carried to the boiling 
point to bring about the flocculent coagulation of the dis- 
solved protein. This procedure is sometimes modified by 
slowly coagulating the proteins, extracted with cold water, 
with the finely divided meat after which the resultant liquid, 
including the flocculent coagulum and small particles of 
meat, is poured from the more solid residual meat. Beef 
tea contains approximately the same constituents as beef 
juice except that the soluble proteins are coagulated and a 
flavor has been developed by cooking. The finely divided 
coagulum is readily digestible. 

Broths are often prepared by the slow cooking of meat 
containing considerable connective tissue and the liquid 
poured off without straining. Such preparations are inter- 
mediate between the ordinary broths and teas; they contain 
considerable gelatin. 

Gelatin. — Gelatin is prepared from collagen-containing 
material, such as connective tissue, tendons, bones, etc., by 
hydrolysis with water (steam). A slight chemical change 
probably takes place in the formation of gelatin. The puri- 
fied product is used for food, while impure gelatin is the basis 
of glue. 

When gelatin is treated with water it swells. In hot water 
it forms a colloidal solution which sets as a jelly upon cooling. 
To such jelly-like masses fruits, fruit juices, etc., are added 
in the preparation of desserts. When heated with acid- 
containing substances gelatin is gradually hydrolyzed into 
non-gelatinizing material; this accounts for its failure to 
"jell" at times. Gelatin is also used in the manufacture of 
ice cream because of the smoothness it imparts to the finished 
product. 



MEA T PREPARA TIONS 187 

Gelatin differs chemically but little from the protein from 
which it is derived. The amino-acids, tryptophan and tyro- 
sine, are not present, or at least they are present in very 
minute quantities; consequently gelatin cannot be used ex- 
clusively as the protein part of the diet. It has been shown, 
however, to be capable of replacing other protein to the ex- 
tent of approximately 60 per cent. When taken with pro- 
teins rich in tryptophan or tyrosine it might replace an even 
greater proportion of other proteins. 



CHAPTER X 

FISH AND SHELL FISH— POULTRY AND GAME. 

FISH AND SHELL FISH 

Fish are an important and an economic source of protein. 
When properly prepared they are fully as palatable as meat 
and in many ways more delicate in texture. The short 
muscle fibers of fish, surrounded as they are by connective 
tissue which is readily hydrolyzed under the ordinary condi- 
tions of cooking, are easily broken apart, and this fact, 
together with their generally low fat content, has placed fish 
among the flesh foods which are easily digested. With the 
increasing facilities for cold storage and the realization that 
when properly stored fish show little change in their composi- 
tion or in their palatability, they should become more widely 
used throughout the year than they now are. 

A large number of fish are used for food ; a choice between 
them is, largely, a matter of taste and economy. When con- 
sideration must be given to their digestibility, the fat con- 
tent becomes the controlling factor, although such fish as cod 
and carp are held to be "coarser" than others. Variety in 
fish is not limited to those freshly caught, for processes of 
preservation have been so developed that fish may be had 
in many forms: those in which they approximate fresh fish 
in every way such as the cold storage and canned fish, or 
those that have been modified in texture or flavor, by dry- 
ing, salting (dried or moist), smoking or preserving in oil. 

Shell fish are another source of protein. They are not, 
however, as important economically as fish. The more 
important kinds of shell fish are (a) mollusks — oysters, 
clams, mussels, and scallops; (b) crustaceans — lobsters, crabs, 
shrimps, and crawfish. Shell fish are used more extensively 
as a delicacy than as a primary source of protein. Oysters, 
however, are often used as a means of modifying the diet 
of invalids, for they are held to be easily digested. 

Fish differs from meat in its chemical composition particu- 
larly in the relative proportions of fat and water. The fat- 
test of the fresh fish commonly used for food contain roughly 
the same proportion of fat as the lean cuts of meat (10 to 12 
per cent, fat), 1 while the lean types of fish contain but a 

Certain cuts of meat, particularly the cheaper ones, are very low in fat, i or 
2 per cent, 



FISH AND SHELL FISH 



189 



fraction of i per cent, of fat. Associated with this lower 
fat content of fish we find a higher percentage of water than 
in meat. Fish have in general, therefore, weight for weight, 
a lower caloric value than meat. The percentage of protein 
is approximately the same in both meat and fish, but it 
tends to be slightly higher in fish. When the extractives 
are omitted from our calculation the nitrogen value of fish 
and meat protein is essentially the same. 

Our knowledge of the qualitative composition, particu- 
larly of the amino-acid content, of fresh fish is very limited. 
In general it appears to be quite similar to that of other 
kinds of flesh (see table, p. 165). Fish contain a relatively 
greater proportion of gelatin-yielding tissue, collagen, and 
a smaller proportion of extractives than do meats. 

The fat of fish is relatively richer in the low melting-point 
fats; it has more of the properties of oils than of " fat " as we 
ordinarily think of fat. 

Carbohydrate is present as glycogen in considerable 
amounts in certain of the fish foods — oysters, clams, scallops. 
It is the glycogen which is in part responsible for the opales- 
cence of the liquor which surrounds oysters. 

The following table contains the composition of certain of 
the more common varieties of fish arranged according to 
their fat content. 



Composition of Typical Fish (Edible Portion). 



Kind. 
Bass 

Blue fish . 
Cod . . 
Flounder 
Trout (brook) 
Weakfish . 



Butter fish 

Halibut 

Herring 

Mackerel 

Salmon 

Shad . 

White fish 





LOW IN 


FAT. 








Protein 






Fuel value 


Water, 


N x 6.25, 


Fat, 


Ash, 


per pound, 


per cent. 


per cent. 


per cent. 


per cent. 


Calories. 


76.7 


20.6 


i-7 


1.2 


455 


78.5 


19.4 


1 .2 


13 


410 


82.6 


16.5 


0.4 


I .2 


325 


84.2 


14.2 


0.6 


1-3 


290 


77-8 


19.2 


2. 1 


I .2 


445 


79 .0 


17.8 

HIGH IN 


2.4 

FAT. 


I .2 


430 


70.0 


I8.0 


II .0 


1.2 


800 


75-4 


18.6 


5-2 


I O 


565 


72.5 


19-5 


7.1 


1-5 


660 


73-4 


18.7 


71 


I .2 


645 


64.6 


22.0 


12.8 


1-4 


950 


70.6 


18.8 


9-5 


1.3 


750 


69.8 


22.9 


6-5 


1.6 


700 



This classification is based, in some cases, upon the analy- 
sis of but one or two fish, and it must be remembered that 
the fat content of fish varies at the time of spawning, differ- 
ent seasons of the year, and with changes in feeding condi- 
tions. Fish are found to have deposited the maximum 



190 FISH AND SHELL FISH— POULTRY AND GAME 

amount of fat just before the spawning season and to have a 
minimum fat content a few weeks afterward. Analyses of 
shad, 1 a comparatively fat fish, illustrate this point. 



Shad, roe not very ripe, April 2 
Shad, roe ripe, April 13 
Shad, roe ready to spawn, May 22 
Shad, after spawning, June 19 



Fat wet basis, per cent. 

• • 14-43 

• • 13-93 

• • 5.87 

• • 2.95 



The same variations have been found to hold for salmon. 
The spawning season for shad is early in April and that for 
king salmon about August and September. The food supply 
also affects the composition of fish; when forced away from 
their accustomed feeding grounds by storms or natural 
enemies, they often arrive on our shores in a very lean condi- 
tion. 

The following table indicates the time of year in which 
fish are in season. 

Fish and Sea Foods in Season. 



Variety. 


Season. 


Black bass. 


All year. 


Blue fish. 


April to December. 


Blue points (shell oysters). 


September to May. 


Buffalo. 


All year (except in time of low water). 


Butter fish. 


March to December. 


Cod. 


All year. 


Cape Cod (large shell oysters). . 


September to May. 


Crappie. 


All year. 


Cat, channel. 


All year. 


Cat, bull head. 


All year. 


Cat, slicing (spoonbills). 


All year. 


Ciscoes (white). 


March to November. 


Carp. 


All year (except in time of low water). 


Crab meat. 


All year. 


Crab flakes. 


All year. 


Crabs, hard shell. 


All year (best season April to October) 


Crabs, soft shell. 


March to October. 


Clams, bulk. 


All year. 


Clams, shell and soft. 


All year. 


Crawfish. 


April to November. 


Eels. 


All year (scarce during winter). 


Frogs. 


February to October. 


Flounders. 


All year. 


Grass pike. 


All year. 


Halibut. 


All year (more plentiful in summer). 


Haddock. 


All year. 


Jack salmon. 


February to November. 


Lobsters. 


All year. 


Mackerel, Spanish. 


May, June, October, November, 




December. 


Oysters. 


September to May. 


Pompano. 


May, June, October, November, 




December. 


Perch, yellow. 


All year. 


Perch, white. 


All year. 


1 Clark and Almy 


U. S. Dept. Agr., 1917. 



FISH AND SHELL FISH 191 

Fish and Sea Foods in Season — (Continued). 



Variety. 


Season. 


Roe, shad. 


January to September. 


Red snapper. 


All year (except in stormy weather). 


Salmon, California. 


March to December. 


Salmon, silver. 


March to December. 


Smelts. 


November to June. 


Sun fish. 


All year. 


Shrimp, fresh. 


September to December; March to July 


Shad. 


January to September. 


Scallops. 


October to May. 


Turtle, soft shell. 


All year. 


Trout. 


April to February. 


White fish. 


April to December. 



The restriction of the fishing industry to certain seasons of 
the year and the difficulties of shipping have resulted in the 
extensive preservation of fish. 

Gold Storage Fish. — Fish are frozen and placed in cold 
storage in this condition (dry packed) or coated with ice. It 
has been found that fish placed in cold storage soon after 
they were caught and analyzed later, shortly after removal 
from the refrigerating plant, showed practically no change 
which could be detected chemically. Results of investiga- 
tions of refrigeration in general indicate, however, that food 
kept in cold storage undergoes a slight modification which 
is not of a harmful nature. Studies of the palatability of 
cold storage fish as compared with fresh fish have showtn tha 
where the subjects were entirely unbiased, cold storage and 
fresh fish were practically indistinguishable. We may con- 
clude, therefore, that cold storage fish which have not been 
kept in the market for more than a day or two are fully as 
palatable as fresh fish. 

Preserved Fish. — Canned fish are subjected to the usual 
process of cooking in the can and sterilizing. With the care 
observed at present in canning fish this form of preservation 
is most satisfactory. The flesh retains most of the charac- 
teristics of cold, cooked, fresh fish. Some fish, particularly 
sardines, are preserved in oil or mustard sauce. In this 
method of canning, the fish are pickled in brine to toughen 
them and to add flavor, cooked with steam, dried, and finally 
packed. In the preparation of dried fish the drying is accom- 
plished by the use of salt, by pressure, or by simply drying in 
the sun or artificially. Dried cod fish are used to a consider- 
able extent and are often sold in a shredded form. Pre- 
served fish are held to be less readily digested than fresh 
fish. 

Cooking of Fish. — Fish flesh is rich in connective tissue. 
The process of cooking hydrolyzes this with the result that 
the short muscle bundles and fibers are easily separated. 



192 FISH AND SHELL FISH— POULTRY AND GAME 

Fish is often boiled in water acidulated with vinegar or lemon 
juice, which tends to toughen the fibers and to coagulate the 
protein on the outside portions and thus keep the fish intact. 
Other processes are employed to the same end, such as slow, 
quiet boiling and wrapping in cloth. 

Digestibility of Fish. — Fish are as thoroughly digested as 
other types of flesh food and meats. Estimations of its 
digestibility show that the protein is absorbed to the extent 
of approximately 96 per cent, and fats 97 per cent. There is 
practically no carbohydrate. Considered from the point of 
view of the ease of digestibility, fish, particularly the lean 
fish, are held to be more readily digested than the lean meats, 
while the fat fish are of the same digestibility as fat meats. 
Cooked fish is more easily masticated and consequently 
more rapidly digested than meat. Oysters are fully as di- 
gestible as lean fish. 

Comparative studies of the digestibility of certain types of 
fish in which the rate of nitrogen excretion and retention of 
nitrogen are taken as indices of digestibility showed that 
absorption appeared to be most rapid in the following order: 
Boiled meats — fresh cod, beef, tan tog, eel, weak fish, mussel, 
salt cod, periwinkle. When the quantity of nitrogen re- 
tained was considered, the order was reversed. Comparison 
of freshly boiled or fried cod and salt cod showed in general 
that while the fish prepared by the former method of prep- 
aration was absorbed more rapidly it was not retained as 
well as the latter. Such data indicate that foods which are 
absorbed at a slower rate furnish the body with protein over 
a longer period of time, the excess at any moment is not so 
great and consequently the body retains a greater propor- 
tion for its use. From these facts it would appear that fish 
is fully as digestible as meat, and, when we consider that it 
is poorer in fat than meat and that the fat of fish has a lower 
melting-point than that of meat, it would seem that fish 
should be, perhaps, more readily digested than most meats. 

POULTRY AND GAME 

Poultry differs but little in its composition from other 
types of meat. It has in many cases a more delicate flavor 
and the fibers of the flesh are, to a certain extent, more 
tender. Its place in the diet is in the nature of a delicacy 
rather than as a staple form of food. 

The greater ease of digestibility attributed to poultry is 
to be ascribed to tradition more than to fact. Young poul- 
try is comparatively low in fat and for that reason undoubt- 



POULTRY AND GAME 19.3 

edly passes more rapidly from the stomach than foods con- 
taining a greater proportion of fat. Poultry rich in fat, as 
the goose or duck, are, in this respect, much less digestible 
than chicken or turkey. The tenderness of the cooked flesh 
and the ease with which it is masticated, because of the short 
fibers, also contribute toward ease of digestion. Studies of 
the utilization of poultry show, however, that it is not any 
more completely absorbed in the course of normal digestion 
than other kinds of flesh, nor does it pass more readily from 
the stomach than lean meats. 

The low purine content attributed to the flesh of poultry 
as compared with other meats has been shown to be errone- 
ous, for beef and mutton contain very little more purine 
than chicken. The extractive nitrogen in the white muscle 
has been shown to be higher than that of red muscle. Tables 
showing the composition of poultry are to be found on page 
177. 



13 



Chapter xi. 
EGGS AND CHEESE. 
EGGS 

The egg occupies as does milk, an important place in the 
human dietary. It belongs primarily with protein foods — 
although by simple mechanical separation it may be divided 
into a portion containing protein, egg white, and into a portion 
rich in lipins, or fat, egg yolk. The protein of egg is of good 
quality. The yolk is particularly rich in fat-soluble A and 
water-soluble B but deficient in the anti-scorbutic vitamine. 

The egg is prepared for the development of the fertilized 
embryo up to the time that a fully formed chick is capable of 
breaking the shell and continuing its growth with food ob- 
tained by its own effort. The nutritive material for this 
restricted growth, which includes the formation of the skel- 
etal, muscular, and organic systems as well as the mainten- 
ance of the growing tissues, is contained in the yolk, white, 
and shell. Its constituents are therefore both highly nutri- 
tious and concentrated; its dietary usefulness is self-evident. 

Eggs are important not only as a simple food, but also as 
an essential constituent of certain prepared foods — cakes, 
custards, and confectionery. 

Since eggs 1 contain quantities of iron and calcium and are 
also easily digested, they are a desirable supplementary food 
for young children, and an acceptable food for convalescents 
and invalids. 

The egg consists grossly of three parts — shell, white and 
yolk. The relative proportion of these in the egg varies 
somewhat with different breeds of hens; in general they are 
shell, ii per cent.; yolk, 32 per cent.; and white, 57 per 
cent, of the total weight of the egg. These parts may be 
mechanically separated with relative ease. Only the white 
and yolk are used for food. The average weight of the edible 
portion of an egg is 50 grams. 

The following table gives the composition of the various 
parts of the hen's egg. 

1 In this discussion we restrict our remarks to the egg of the hen, unless other- 
wise stated. The egg of the duck, goose, turkey, guinea fowl, many wild fowl, 
and certain amphibians, as turtle and alligator, are used for food, but seldom to 
the extent to which the hen's egg is utilized. Their properties are very similar. 



EGGS 195 

Comparative Composition of the Edible Portions of the Egg. 1 

Edible 
portion 

(whole egg), White, Yolk, 

Constituents. per cent. per cent. per cent. 

Water 73-7 86.2 49.5 

Protein 13.4 12.3 15.7 

Fat 10.5 0.2 33.3 

Ash 1.0 0.6 1.1 

Potassium, K2O » 0.165 0.19 0.13 

Sodium, Na2<3 0.2 0.21 0.1 

Calcium, CaO 0.093 0.015 0.2 

Magnesium, MgO 0.015 0.015 ° 02 

Phosphorus, P2O5 0.37 0.03 1.0 

Chlorine, CI 0.10 0.15 0.1 

Sulphur, S 0.19 0.20 0.16 

Iron, Fe 0.003 0.0001 0.0085 



50.0 


33 -o 


17.0 


1.8 


1.2 


0.6 


74.0 


17.0 


60.0 


68.0 


194.0 


28.0 



Weight of average egg, grams 
Weight of average egg, ounces . 
Fuel value, average egg, calories 
Weight, 100-Calorie portion, grams 

Egg White. — Egg white, when raw, is a viscous, semiliquid 
mass having a slightly greenish tinge and practically no 
flavor; the reaction of the egg, when fresh, is very slightly 
alkaline. It consists almost entirely of protein, water and 
salts; though a small amount of carbohydrate is present. 
Water predominates, as it does in all animal tissue or pro- 
ducts. There are several proteins in egg " albumen," oval- 
bumin, conalbumin, ovoglobulin, ovomucin, and ovomu- 
coid. The albumins which predominate and comprise ap- 
proximately 90 per cent, of the total protein are similar in 
composition. They differ in their ability to crystallize from 
a solution of ammonium sulphate. Ovoglobulin exists to 
the extent of about 6.5 per cent, of the total protein; it is 
probably not an individual protein but a compound. The 
glycoproteins, mucin and ovomucoid, are present in small 
amounts. Egg white is practically free from fat. The in- 
organic constituents of the egg white are chiefly phosphorus 
and calcium. The sulphur in albumen is the source of the 
hydrogen sulphide in the spoiled egg. 

Egg Yolk. — Egg yolk is particularly rich in lipins (fats 
and lipoids). The relatively high caloric value of egg yolk, 
approximately seven times that of egg white, is to be ascribed 
to its lipin content. The lipin constitutes approximately 
20 per cent, of the solid constituents of the yolk. The gly- 
cerides of palmitic acid, 38 per cent.; stearic acid, 15 per 
cent.; and oleic acid, 40 per cent., are the principal fats 
present. Of the lipoids, lecithin is present to the extent of 

1 Compiled from Sherman: Food Products, 1914. 



196 EGGS AND CHEESE 

approximately n per cent, and cholesterol 1.5 per cent. 
The composition of egg fat varies with the diet of the hen; 
certain characteristics of ingested food are often transferred 
to the egg and modify the color, odor, or taste. The color 
of eggs particularly varies with the nature of the ingested 
food; green vegetables, etc., tend to produce a darker colored 
yolk than do other foods. The feeding of fish affects the 
taste of eggs and it has been shown that benzoic acid when 
fed to hens appears in the egg. The lipins exist in egg yolk 
as a fine emulsion. The low melting-point of egg fat and the 
fact that the fat is highly emulsified make the yolk easy to 
digest and therefore valuable as a food for the sick. 

Of the proteins in egg yolk, the phosphoprotein, vitellin, 
is the most important. It has been shown that vitellin 
exists in the yolk as a lecithin-nucleovitellin compound or 
mixture containing from 15 to 30 per cent, of lecthin com- 
bined with a lecthin-free substance which has been designated 
nucleovitellin. Purine bases are practically absent from the 
egg; they are contained only in the nucleus of the yolk. 

Eggs and particularly egg yolk are a good source of phos- 
phorus, iron, and calcium. The phosphorus occurs almost 
entirely as organic phosphorus — lecithin and vitellin; certain 
other phosphorus-containing lipoids are also present. Iron 
is in organic combination. It exists in a complex molecule 
which contains in addition to carbon, hydrogen, oxygen, 
and nitrogen: iron, 0.455 per cent.; calcium, 0.352 per cent.; 
and magnesium, 0.126 per cent. This compound has been 
called hematogen because it is supposed to be the precursor 
of hemoglobin. The composition of the compound has not 
been found to be the same under different methods of prepar- 
ation; it may be a mixture of substances. The ash of egg 
is predominantly acidic. 

The table on page 195 shows the quantity of the more 
important mineral constituents of egg in the percentage of 
the total ash. 

Cooking of Eggs. — Eggs are prepared for the table by 
boiling in the shell, dropping into hot water (poaching), 
or frying over a hot plate. The degree of coagulation of 
both white and yolk in boiled eggs is a matter of great per- 
sonal taste and habit. There are three average degrees of 
hardness to which an egg may be boiled — soft-cooked, in 
which the white resembles a soft, thick curd and the yolk 
is fluid; medium-cooked, in which the white is firmer though 
still soft and tender, and the yolk is thickened, and hard- 
cooked, in which both the white and yolk are completely 
coagulated and quite firm. A certain flavor is developed 



EGGS 197 

upon cooking which is best in the medium-cooked egg. Of 
the three methods of boiling eggs: cooking in continuously 
boiling water for a certain length of time; or placing in cold 
water and bringing it to a boil; or placing in boiling water 
which is no longer heated, the last, which involves cooking 
below the boiling point, is the best, both for the consistency 
of the white and yolk and, as we shall see, for its digesti- 
bility. With this procedure the texture of the egg can be 
readily controlled. It has been found that an egg taken 
from the ice-chest, when placed in one pint of water, in a 
quart stew pan, which has been brought to a boil over a gas 
flame and allowed to remain six minutes was soft-cooked; 
the temperature of the water dropped from (212 F.) the tem- 
perature of boiling water to 185 F. upon the addition of the 
egg, and then steadily to I70°F. If the egg remained in the 
water eight minutes it was medium-cooked and the tempera- 
ture of the water had fallen to 162 to 164 F. These data 
relate to one egg. For a greater number of eggs the amount 
of water must be increased proportionately or the time 
lengthened. A little experience will fix the time required 
for conditions which differ from those outlined above. 

Poached eggs are similar in consistency to boiled eggs. In 
this case the yolk and white are coagulated in the water 
instead of in the shell and there is undoubtedly a slight but 
negligible loss of mineral matter. 

Fried eggs are cooked at a relatively high temperature 
with the use of fat of some kind, factors which increase the 
flavor of the eggs but which tend to decrease the ease with 
which they are digested. 

The function of the egg in cakes, in addition to its fuel 
value, is to ensure lightness. Egg protein plays the most 
important role in the process. As the result of whipping or 
beating fine bubbles of air are incorporated into the viscous 
egg. When this beaten mass is mixed with the other ingre- 
dients and cooked, the expansion of these air bubbles and 
other gas bubbles formed by the leavening agents and the 
coagulation of the surrounding protein produce the comb- 
like structure indicative of "lightness" in such foods. 

Digestibility of Eggs. — From a quantitative point of view 
egg protein is as digestible as meat or milk protein ; the pro- 
tein and fat of eggs show a high degree of absorbability. 
Egg white, raw or soft-boiled when fed alone tends to leave 
the stomach more rapidly than other protein material. Raw 
egg white has been observed to begin to pass from the stom- 
ach, without becoming acidified, almost immediately after 
ingestion. Later the remaining food becomes acid and passes 



198 EGGS AND CHEESE 

out more slowly. It is interesting in this connection to 
know that raw egg white does not excite the flow of the gas- 
tric juice any more than water does. 

Cooked egg white passes from the stomach at a rate which 
appears to depend more upon its consistency than on the 
extent to which it is cooked. Particles of " hard-boiled" 
eggs leave at a slower rate than soft-boiled eggs, although 
thorough mastication tends to increase the rate of evacua- 
tion. 

In a comparative study of the digestibility of eggs cooked 
in various ways it was found that eggs when eaten raw, or 
after being soft or hard-boiled had completely left the stom- 
ach at the end of periods as follows : 

Raw i hour, 10 minutes 

Soft-boiled i}4 hours 

Hard-boiled 2}4 hours 

The amount of gastric juice poured out in each case was: 

Raw 399 c.c. 

Soft-boiled 372 c.c. 

Hard-boiled 481 c.c. 

While raw egg leaves the stomach much more rapidly than 
soft-boiled egg it has been repeatedly shown that it is not so 
rapidly or completely digested in a given time in the stomach 
or upper part of the small intestine as soft-boiled eggs. 
Large quantities of raw egg white may cause diarrhea. The 
indigestibility of raw egg white is related to its chemical 
constitution, or perhaps to the presence of antitrypsin, than 
to its physical texture. When considered on the basis of 
the rate of elimination of nitrogen, raw and hard-boiled eggs 
are not as rapidly absorbed as other protein substances, e. g., 
meat, gelatin, or casein. This has been ascribed for raw egg 
to the short time which it stays in the stomach and to the 
possibility that its digestion is difficult in the intestine. In 
the case of coagulated egg white the slowness of absorption 
has been ascribed to the compactness and impermeable 
character of the particles. 

Preserved Eggs. — The fact that a greater number of eggs 
are produced at certain seasons of the year than at others 
has led to the practise of storing them in the refrigerator 
and otherwise preserving them in salt, water-glass, etc., and 
by desiccation and freezing. Eggs kept in cold storage 
change slightly, as do all cold storage products according to 
the length of time they are kept there. They gradually 
develop a taste and odor different from that of a fresh egg. 
Water passes from the white to the yolk with a resultant 



CHEESE 199 

increase in the size of the yolk and, if the increase be suffi- 
ciently great, the yolk membrane is weakened or ruptured. 
Moisture is lost through evaporation. There is an altera- 
tion in the properties of the white, upon which its value for 
cooking depends, perhaps as the result of autolysis. These 
changes do not develop sufficiently in a period of a month 
or six weeks to alter the characteristics of the egg from those 
of a moderately fresh egg. Eggs kept for a greater time 
show proportionately greater change. 

One of the most important objections to cold-storage eggs 
is that they are usually sold for fresh eggs. Good cold- 
storage eggs are very useful in cooking and are often nearly 
as palatable as fresh eggs. When eggs are sold as " cold- 
storage" eggs they are an important economic factor in the 
diet. Present methods of rapid drying yield dried-egg pre- 
parations which are satisfactory for cooking and general use 
where the intrinsic character of fresh eggs is not an essential 
consideration. The objection to dried eggs has been that 
they are sometimes prepared from decayed eggs. When it 
is known that they are properly prepared from fresh eggs 
they are satisfactory for use as indicated above. 

Egg Substitutes. — Preparations which consist of some 
form of protein and a small amount of coloring matter are 
placed on the market as substitutes for eggs. Custard 
powders are offered which are essentially starch and seldom 
contain egg and often no protein. 

CHEESE. 

Cheese is a preparation made from milk or cream by coagu- 
lating the caseinogen with rennin. The casein thus formed 
is subjected to the action of bacteria, moulds or enzymes 
which "ripen" the cheese, producing changes in the flavor, 
consistency, and composition of the product. Cheese, with- 
out any designation to indicate a modification, contains 
approximately one-third each of water, protein, and fat; 
that is, roughly, 50 per cent, of the solid matter is butter 
fat. The designations, "cream," "full cream," "whole 
milk," and "milk," although used more or less interchange- 
ably in this country, indicate that the cheese is made from 
whole milk or sometimes from milk and cream. Some 
cheeses are made from skimmed milk "filled" with fat other 
than butter fat, as lard, cotton-seed oil, etc. Goat's milk 
is sometimes used in preparing cheese, The greater propor- 
tion of American cheeses are, however, made from cow's 
milk. Cheese, from the mode of preparation, is then a 



200 EGGS AND CHEESE 

combination of the greater portion of the protein, caesinogen 
and the fat of milk. It contains a large proportion of cal- 
cium and phosphorus combined with the casein and a smaller 
proportion of the other salts and lactose present in milk; 
salt (sodium chloride) is added in the process of manufac- 
ture of cheese. 

There are two types of cheese: the hard cheeses of the 
Cheddar, "American cheese," type (Cheddar, Edam, Em- 
mental (Swiss), Parmesan, and Roquefort) and the soft 
cheeses (brie, camembert, gorganzola, Limberg, Neufchatel, 
and Stilton). These cheeses vary in their consistency and 
flavor according to the manner of preparation. Cottage 
cheese is a term applied to "unripened" casein and is usu- 
ally prepared at home from sour milk, although it can be 
obtained from dairies in many cases. 

In the process of ripening there is an increase in the soluble 
protein (proteose, peptone and amino-acids), indicating a 
partial digestion of the protein; while the fat is not so com- 
pletely emulsified as in milk, it does not appear to undergo 
any extensive modification. 

The composition of cheeses of various fat content in com- 
parison with other milk products is given on page 152. 

Digestibility of Cheese. — Cheese is as completely utilized 
as other protein foods. Its digestibility has been shown to 
be approximately equal to that of meat, eggs, etc. The 
general opinion that cheese is indigestible is due to the fact 
that the casein of cheese is associated roughly with an equal 
quantity of fat which tends to prolong its stay in the stomach 
and that the volatile fatty acids and certain of the protein 
cleavage products formed during the ripening process may 
be irritating to the stomach. Careful chewing of cheese 
when eaten alone should increase the "ease" of digestibility, 
for the finely divided particles will tend to leave the stomach 
more rapidly than the larger pieces of cheese. 

Cheese should be served with starchy foods and vegetables, 
for it is rich in protein and fat and very poor in carbohydrate. 
When so served it is a most desirable article of diet. Since 
cheese is comparatively cheap it may be used to advantage 
in the variation of the protein part of the diet in place of 
meat and fish. 

Casein Preparations. — A number of specially prepared 
foods can be obtained whose base is chiefly casein. These 
may be the dried calcium caseinate obtained from milk with 
additional food-stuffs, or the water soluble salt, or salts of 
the stronger alkalies, sodium or potassium; glycerophos- 
phates are sometimes added. The nutritive value of these 



CHEESE 201 

preparations is approximately that of casein. The thera- 
peutic value which is claimed for many of them is probably 
overestimated for the same quantity of casein taken as milk 
or freshly coagulated skimmed milk or even as soft cheese 
(cottage cheese) undoubtedly possess all the advantages of 
these preparations and in addition the constituents of milk, 
fat, salts, lactose, and accessory substances, which have been 
shown to be in many ways desirable. The prepared products 
are desirable in diets which are too low in fat and sugar, or 
where the protein content is to be increased without an in- 
crease in bulk. For further discussion, see section on Clini- 
cal Dietetics. 



CHAPTER XII. 
PROTEIN-RICH VEGETABLE FOODS. 

LEGUMES 

Certain vegetable foods, particularly the legumes, are 
rich in protein, and are at the same time comparatively poor 
in carbohydrate; others, such as nuts, contain considerable 
quantities of fat. It is desirable to classify these foods as 
protein-rich foods. The grains, wheat, barley, oats, corn, 
etc., are likewise comparatively rich in protein (10 to 12 per 
cent.). Carbohydrate predominates, however, and this fact 
together with the place of these foods in the average diet, 
serves to differentiate them into the class of carbohydrate 
foods. The legumes and nuts are preserved in a semidried 
state in which they may be kept almost indefinitely. Their 
low water content and comparatively high protein content 
make them a valuable source of protein when transporta- 
tion is a problem, as in hunting and campaigning in war. 
These foods are relatively cheap and are therefore a valuable 
source of protein in diets of low cost. 

The legumes are of lower biological value when used as 
the chief constituent of the diet; their proteins are of lower 
value than those of milk; they are relatively poor in fat- 
soluble A and the anti-scorbutic vitamine, and they are poor 
in calcium, sodium and chlorine. When corrected for these 
deficiencies by the inclusion of the proper foods the legumes 
are a valuable and economical constituent of the diet. 

The vegetable and animal proteins are in many ways simi- 
lar in both their physical and chemical properties. In gen- 
eral, vegetable proteins yield more glutamic acid and in 
some cases proline, arginine and ammonia than do the animal 
proteins. Many of them are deficient in one or more essen- 
tial amino-acids but they do not differ in this respect from 
certain animal proteins (gelatin). In seeds, the form of 
vegetable protein food with which we are particularly con- 
cerned, most of the protein is found in the endosperm, as 
reserve protein surrounding the embryo. Proteins of the 
globulin, glutelin and prolamine type predominate in the 
endosperm. Legumes are particularly rich in globulins, 
the legumins. These proteins form salts with calcium which 
are insoluble in water. It is the formation of these com- 

202 



LEGUMES 203 

pounds which accounts for the difficulty encountered in 
cooking peas and beans in hard water — the failure to soften. 
The use of water poor in calcium, as distilled water, or water 
softened with sodium carbonate, overcomes the difficulty. 
In addition to these proteins the embryo contains others 
which are more varied in character and apparently similar 
to the physiologically active animal proteins, as albumin, 
nucleoprotein. The following proteins have been found by 
Osborne to be present in wheat: 

Spring wheat, Winter wheat, 

per cent. per cent. 



Glutenin 4.68 4.17 

Gliadin . 
Globulin 
Albumin 



Proteose 



3 96 3-90 

o . 62 o . 63 



0.39 0.36 

0.21 0.43 



It is from the nucleoprotein in the embryo that the greater 
proportion of the small amount of purine bases contained 
in the legumes and nuts is obtained. The following table 
gives the quantity of purine bases in certain of these foods. 

Purine Bases in Vegetable Foods. 

Present percentage of purine base 
Practically absent. nitrogen. 

White bread Oatmeal 0.021 

Rice Pea meal .... 0.016 

Tapioca Beans 0.025 

Cabbage Lentils 0.025 

Lettuce Potatoes 0.0008 

Cauliflower Onions 0.0031 

Asparagus (cooked) . 0.0086 

The difference in composition between fresh and dried 
legumes is to be ascribed to variations in the water content. 
Fresh shelled beans and peas contain a large proportion of 
water. The removal of water in drying is accompanied by a 
relative increase in the nutritive constituents. The table on 
page 240 gives the composition of typical fresh and dried 
legumes rich in protein. 

In the preparation of the dry legumes for consumption a 
considerable amount of the water lost in drying is restored, 
thus yielding a food of considerable bulk in proportion to its 
protein content. This comparatively large bulk of legumes 
which must be ingested to furnish the requisite amount of 
protein constitutes one of the chief objections to a vegetarian 
diet. 

The fat content of legumes is low. There are, however, 
one or two exceptions; soy beans and peanuts are compara- 
tively rich in fat. Accompanying the high fat content of 
these legumes we note a smaller proportion of carbohydrate. 



204 



PROTEIN-RICH VEGETABLE FOODS 



The legumes have a relatively high ash content. Potassium, 
phosphate, and iron are abundant: the proportions of these 
and of other ash constituents will be found below. 

Comparative Composition of Protein-rich Vegetable Food with 
Other Foods (Edible Portion). 









Protein 




Carbo- 




100-Calorie 




Water, 


(NX6.25), 


Fat, 


hydrate, 


Calories 


portion, 




per cent. 


per cent. 


per cent. 


per cent. 


per pound. 


gm. 


Legumes, dried 


12.6 


22.5 


1.8 


59-6 


1567 


29 


Legumes, fresh 


68.5 


7-1 


O.7 


22.0 


557 


82 


Nuts . . 


2.4 


18.4 


64.4 


13.0 


3182 


14 


Cereals . 




I2.0 


II. 4 


I .0 


75-i 


1610 


28 


Lean meat 




70.0 


21-3 


7 9 




652 


64 


Dried beef 




54-3 


30.O 


6-5 


0.4 


840 


56 


Fish, lean 




75-4 


18.6 


5-2 




550 


83 


Milk 




87.1 


3-3 


4.0 


50 


3H 


145 


Cheese . 




35-0 


27.7 


36.8 


4.1 


2080 


22 


Eggs 




73-7 


13-4 


10.5 




672 


68 



Soy Bean. — The soy bean is particularly rich in protein, 
contains a high percentage of fat, and is poor in carbohydrate. 
The sugar content is relatively high. In China and Japan 
the soy bean is prepared in various ways in the form of 
cheeses and sauces in which the beans are cooked, mixed 
with various grains and subjected to the action of bacteria— 
shoyu, natto, miso — or precipitated and, after removing 
most of the water, pressed into cakes or tablets (tofu). Be- 
cause of its low starch and high fat and protein content the 
soy bean has assumed an important place in the diet of 
the diabetic. The carbohydrate is chiefly in the form of 
sucrose, hemicellulose, and cellulose. The following data 
give the result of the analysis of a soy bean : 



Soy Bean (Hollybrook). 1 



Water .... 

Ash 

Protein (N x 6.25) . 
Ether extract 
Nitrogen-free extract 



Per cent. 
12.67 

4 ■' 
36. 



Constituents in Nitrogen-free Extract. 



Galactan 4.86 

Pentosan 4-94 

Raffinose 1 . 13 

Starch 0.50 

Cellulose " 3 2 9 

Undetermined hemicelluloses 0.04 

Dextrin 3 .14 

Sucrose 3. 31 

Invert sugar 0.07 

Organic acids (as citric) . ^ . . 1.44 

Waxes, color principles, tannins, etc. (by difference) . . . 8 . 60 



1 Street and Bailey: Jour. Ind. and Eng. Chem., 1915, vii, 853. 



LEGUMES 205 

The quantity of sucrose and starch present in the soy 
bean varies chiefly with the manner in which the bean is 
allowed to ripen or the time at which it is gathered. Those 
which are not permitted to ripen thoroughly or which are 
allowed to ripen after the vine is cut are more likely to con- 
tain starch than others. Beans which are permitted to be- 
come thoroughly ripe are practically free from starch. 

Peanut. — The peanut, like the soy bean, is rich in protein 
and fat and poor in carbohydrate, and is therefore a most 
satisfactory diabetic food. Peanut butter, prepared from 
peanuts by grinding, is even richer in protein and fat than 
the untreated peanut itself. 

Preparation of Legumes. — Legumes are prepared for the 
table by boiling in water, baking, or roasting. Partially 
broken or ground into flour the legumes are used in soups: 
split-pea soup, for example, is a most palatable and nutritious 
dish. The effect of cooking legumes is to soften the cellu- 
lose structures, hydrate the starch, coagulate the protein and 
develop flavor. Fresh peas and beans are cooked without 
other preparation than the removal of their pods. Since the 
cellulose is still soft, the time required for cooking is com- 
paratively short. Dried legumes, however, must be soaked 
in water, swollen, before they are cooked, and, because of the 
hardened condition of the cellulose must be heated for a 
long time to ensure the complete softening of the cellulose 
and the rupture of the starch granules. Soaking of dried 
legumes in some cases permits the removal of the indiges- 
tible skin surrounding the bean or pea. Certain bitter con- 
stituents are also removed in the soaking process. To pre- 
vent the formation of insoluble calcium-protein compounds, 
which occurs when hard water is used, legumes should be 
soaked and cooked in soft or distilled water. 

The digestibility of dried legumes, even after cooking, is 
slightly lower than that of the flesh foods. Digestion experi- 
ments show that while the carbohydrate and fat — usually 
added to them in preparation — are readily digested and 
absorbed, the protein is not completely digested; the degree 
of digestion is estimated at approximately 80 per cent, for 
legumes, as compared with 95 per cent, for meat. That the 
low digestibility of legumes is due largely to the cellulose 
structures which prevent digestion and absorption is shown 
by the greater digestibility of the cooked food and the fact 
that the protein of finely ground legumes is practically as 
well absorbed as meat protein. 

The general contention that legumes are indigestible has 
been ascribed to the consciousness of the digestive processes 



206 



PROTEIN-RICH VEGETABLE FOODS 



experienced following the ingestion of these foods. Such 
indications are heightened in some people by the flatulence 
which often occurs during digestion. The economic import- 
ance and food value of legumes have been discussed on page 

145. 

Nuts. — Nuts are seldom used as a staple article of diet. 
They might well be so used, for they are particularly rich in 
both protein and fat. Studies of the digestibility of nuts 
are few. It has been shown that in a fruit-and-nut diet the 
food constituents are practically as digestible as those of a 
mixed diet. 



Digestibility of Fruits and Nuts. 

Fruits and nuts. 

Protein 90 

Fat 85 

Starch and sugar 96 

Crude fiber 54 

Ash 68 

Energy 86 



Mixed diet. 

94 
92 
96 
49 



The protein is, however, slightly less digestible. Nuts 
are generally held to be, physically, indigestible because 
they often produce a feeling of discomfort upon ingestion. 
This is no doubt largely due to excessive ingestion and poor 
mastication. The high fat content of nuts will tend to re- 
tard the passage of food from the stomach and this delay 
may also be a contributing factor to the conception of indi- 
gestibility. When eaten properly, nuts are a digestible and 
valuable food. A diet of nuts and cereals and vegetables 
has recently been shown to be a satisfactory diet for the 
production of milk by women. The accompanying table 
gives the composition of the more important nuts. 

Composition of Typical Fruits and Nuts (Edible Portion). 









Protein 






Carbo- 




100-Calorie 




Water, 


(NX6.25), 


Fat, 


hydrate, 


Calories 


portion. 




per cent. 


per cent. 


per cent. 


per cent. 


per pound. 


gm. 


Almonds 


4 8 


21 .0 


54-9 


17-3 


2940 


15 


Brazil nuts . 


5 


3 


17.0 


66 


8 


7 





3162 


15 


Chestnuts, fresh 


45 





6.2 


5 


4 


42 


1 


IO97 


43 


Chestnuts, dried 


5 


9 


IO.7 


7 





74 


2 


1828 


25 


Cocoanut 


14 




5-7 


50 


6 


27 


9 


2675 


17 


Hickory nuts 


3 


7 


15-4 


67 


4 


11 


4 


3238 


14 


Peanuts 1 


9 


2 


25-8 


38 


6 


24 


4 


2490 


18 


Pecans . 


2 


7 


96 


70 


5 


15 


3 


3330 


14 


Walnuts, California 


2 


5 


18.4 


64 


4 


13 





3200 


14 



Legume 



CHAPTER XIII. 
CARBOHYDRATE-RICH FOODS. 

Carbohydrates are one of the two important classes of 
energy-yielding food-stuffs. Studies of the respiratory quo- 
tient of men have demonstrated repeatedly that when the 
body has a choice between fat and carbohydrate to be used 
in the production of energy or work, particularly when there 
is a sudden call upon the body resources, carbohydrate 
(glucose) is the first to be utilized and, when this is gone, the 
fats. When carbohydrates are entirely lacking in the diet, 
or have been withdrawn from the body, marked disturbances 
in metabolism occur, particularly in fat metabolism. The 
chief disturbance is evidenced by an incomplete oxidation of 
the fats, resulting in a condition known as acidosis. The 
evidence is, for man at least, that carbohydrate is essential 
to the normal continuance of body functions, and that when 
this is not supplied in the food, it must be formed from pro- 
tein. 

In considering carbohydrate foods we will include those 
foods in which carbohydrates predominate. Such a classi- 
fication includes some foods, such as cereals, which are com- 
paratively rich in protein; their chief place in the diet is, 
however, as a source of carbohydrate. This classification 
also excludes the legumes which contain a rather large pro- 
portion of carbohydrate, but their place in the diet justifies 
their classification with the protein-rich foods. The potato 
and banana will also be considered here, for even though 
they might be classed with the succulent vegetables and 
fruits, they serve as valuable sources of carbohydrate. 

For dietetic purposes, carbohydrates are quite often classi- 
fied as sugars, starches, and cellulose. Such a division is 
sufficient for most practical purposes; it does not, however, 
serve for differentiation on the basis of their chemical com- 
position. The following classification is based upon the 
relative complexity of the carbohydrate molecule: 
I. Monosaccharides. 

i. Pentoses, C 5 H u 5 : {a) Arabinose; (b) xylose (c) 

rhamnose (methyl-pentose) , C 6 H 1 2 5 . 
2. Hexoses, C 6 Hi20 6 : (a) Glucose; (b) frutose; (c) 
galactose. 



208 CARBOHYDRATE-RICH FOODS 

II. Disaccharides, C12H22O11: (i) Maltose; (2) lactose; (3) 
isomaltose; (4) sucrose. 

III. Trisaccharides, C28H32O16: (1) Raffinose. 

IV. Polysaccharides (C 6 H 10 O 5 ) x : (1) Gum and vegetable 

mucilage group: (a) Dextrin; (b) vegetable gums. 
(2) Starch group: (a) Starch; (b) inulin; (c) glyco- 
gen; (d) lichnin. (3) Hemicellulose group: (a) Cel- 
lulose; (b) hemicellulose. (1) Pentosans, gum ara- 
bic; (2) Hexosans, galactans, agar agar. 
The carbohydrates of particular dietetic importance are 
the monosaccharides, having six carbon atoms, the hexoses, 
or compounds whose molecules are multiples of these, such 
as the starches. 

SUGARS. 

The term sugar is, by convention applied to the disaccha- 
ride sucrose obtained chiefly from the juice of the sugar-cane, 
sugar-beet, and maple tree. Other simple mono- and disac- 
charides, such as glucose (dextrose or grape-sugar), fruc- 
trose (levulose or fruit-sugar), lactose (milk-sugar), maltose 
(barley or malt-sugar) are also classed among the sugars. 
The sweetness of various fruits and vegetables is due either 
to sugar, its products of hydrolysis or a combination of these. 
Unless it is specifically defined or inferred, the term sugar 
applies, in the following discussion, only to sucrose. 

Sucrose. — Sugar (cane-sugar, beet-sugar, sucrose) is widely 
distributed in the vegetable kingdom. Upon digestion or 
hydrolysis it yields one molecule each of fructose and glu- 
cose. The combined effect of these two sugars upon polar- 
ized light is to rotate it in the opposite direction from that 
produced by the solution of sucrose from which it was ob- 
tained. For this reason the hydrolyzed mixture is called 
invert sugar. 

The sugar of commerce is obtained almost exclusively 
from the sugar-cane and the sugar-beet. There is often a 
discrimination between the two. Cane-sugar is supposed to 
be purer and more satisfactory for certain culinary processes, 
such as canning and jelly making. As far as the sucrose is 
concerned there is no difference, and between the highest 
commercial grade of each there is no distinction. The 
cheaper grades of beet-sugar may have a bitter taste or an 
odor suggestive of glue. 

In the manufacture of sugar the juice is expressed (cane- 
sugar) or extracted (beet-sugar), treated with lime to clarify 
it, filtered, and evaporated in vacuo. Upon standing the 
first crop of crystals separate from the concentrated liquid. 



SUGARS 209 

The mother liquid or first molasses is removed by draining 
or by centrifugal force. This liquid is then diluted and a 
second lot of sugar and molasses obtained. This process is 
often carried out for a third time. The yellowish or brown 
sugar obtained by crystallization from the molasses is usu- 
ally refined by redissolving, clarifying, decolorizing, and 
finally recrystallizing. Crude cane-sugar is often sold as 
brown sugar. Crude beet-sugar, however, has a rather un- 
pleasant flavor, and is not usable. 

In addition to the final product, sugar, the molasses or 
mother liquid remaining after the first crystallization from 
the juice of the sugar-cane and the mother liquor from the 
crystallization of the refined sugar are used as food. The 
latter is often mixed with glucose, or corn syrup, and sold as 
"corn syrup with cane flavor." 

Glucose. — Glucose (dextrose or grape-sugar) is found most 
widely distributed in the plant and animal kingdom. It 
occurs in the free state and in combination with other sugars. 
It is the end-product of the digestion of starch, glycogen and 
maltose, and one of the products of the hydrolysis of sucrose 
and lactose. In the body it is the form of carbohydrate 
present in the blood. Glucose is assuming an important 
place in the manufacture of syrups and confections and is 
often used by manufacturers in place of cane-sugar. It is 
prepared from starch by the action of acids which hydrolyze 
it, yielding a product known as "commercial glucose," or 
"corn syrup," a viscid liquid mixture of glucose, maltose, 
and dextrin. The complete hydrolysis of starch yields prac- 
tically pure glucose which upon recrystallization, is sold as 
starch-sugar or grape-sugar. 

Glucose is often used in the preparation of preserved fruit 
products and as such it is considered an adulteration. Many 
artificial jams or fruit butters are prepared from apple pulp 
which, when flavored and colored, are sold as jams of differ- 
ent kinds. The present pure food laws require such prepara- 
tions to be labelled as artificial. As far as their food value is 
concerned they are as satisfactory as the true products. 

Lactose. — Lactose, the sugar in milk, yields galactose and 
glucose upon hydrolysis. It is not as sweet as cane-sugar 
and is therefore often a valuable food in cases where it is 
desired to raise the caloric value of the diet. It is a concen- 
trated form of carbohydrate, and is readily absorbed. Fur- 
ther, it has been shown that fermentation in the stomach 
does not take place as readily with lactose as with sugar. 
Coleman has used lactose successfully to increase the caloric 
value of the diet of typhoid fever patients. 
14 



210 CARBOHYDRATE-RICH FOODS 

Maltose. — Maltose, one of the digestive products of starch, 
is composed .*of two molecules of glucose. It occurs in the 
diet^usually^as the result of special preparation, as in the 
preparation ofjmalt or the preliminary digestion of food. 

Maple-sugar. — Maple-sugar is obtained from the sap of 
the sugar-maple. The sap is evaporated in open kettles and 
the sugar allowed to crystallize into a solid mass. Maple- 
sugar is seldom refined; it contains in addition to the sugar 
certain ethereal substances and organic acids which give to 
it the characteristic flavor. When the concentrating pro- 
cess is not carried far enough for the sugar to crystallize, 
maple syrup is obtained; the greater part of the sugar from 
the maple tree is sold in this form. 

Invert Sugar. — Invert sugar, a mixture of equal parts of 
glucose and fructose, is seldom sold as such. It is found in 
ripejfruits and vegetables, molasses from cane-sugar, and 
often in jellies and confections as the result of hydrolysis. 

Fructose. — Fructose (levulose or fruit-sugar) is found in 
fruit associated with glucose, as invert sugar (see above). 
Inulin, the starch-like substance in the roots of the dande- 
lion, chicory and the tubers, and of artichokes yields fructose 
upon hydrolysis. 

Candy, Jams and Jellies. — The sugars are important con- 
stituents of confectionery, preserves and jams. Candy is 
essentially cane-sugar or glucose to which certain flavoring 
and coloring substances and sometimes a rilling material has 
been added. In the commercial preparation of many candies 
sugar is partially hydrolyzed to invert sugar, which gives 
them a greater smoothness. 

Preserves, jams, and jellies aie essentially fruit pulp or 
juice to which sugar has been added and the whole boiled to 
the proper consistency. Their food value is largely due to 
the sugar. The gelatinizing constituent of jellies is the 
pectin of the fruit. When pectin is deficient it is often 
obtained from other fruits, giving the mixed jellies. Acid 
is also necessary in the preparation of jellies, for it aids 
in the gelatinization of pectin and in the inversion of the 
sugar. In the latter process a large proportion of the added 
cane-sugar is "inverted" into non-crystallizing invert sugar. 
This is an important consideration in preparing such products 
for otherwise the cane-sugar would crystallize and the jelly 
or jam would be physically unpalatable. The table on 
page 211 gives the comparative composition of the expressed 
juice and pulp and of the jelly and jams prepared from 
them. 



SUGARS 



211 



Digestion and Utilization of Sugar. — We will confine our 
discussion to the utilization of sucrose and its products of 
hydrolysis, for the quantities of the other sugars ingested are 
comparatively small. The only important exception is the 
lactose in milk, the source of carbohydrate in the diet of 
infants. The digestion of sugars takes place wholly in the 
intestines. They are there transformed, in the processes of 
digestion, into monosaccharides and in that form are com- 
pletely absorbed. 

Composition of Jams and Jellies and the Juices from Which They 

were Prepared. 

Sugars. 





1 




c 


S 




X 




(fc 




4> 

u 


u "t! 


z* 




o. 






■5 c 


- to 








4) 


u 


•S ° 




u 




a 








<v 








'33 i- 










•O 4> 


-4-> <U 




rt 




.c 


& 


a 




£ 




to 

< 


< 


£ 


Grape : 












Juice 


• 91 


2 


0.57 


O.9O2 


0.237 


Jelly 


• 36 


3 


0.45 


O.524 


0.175 


Pulp 


• 87 


5 


0.75 






Jam 


• 43 


4 


0.48 


O.744 


0525 


Orange: 












Juice 


• 93 


9 


0.36 


0.297 


0.581 


Jelly 


• 3i 


4 


0.30 


0.171 


0.418 


Pulp 


. 86 


9 


0.61 


0.686 


0.985 


Jam 


• 19 


5 


0.44 


0-433 


0944 



. 10 




0. 


.29 


60.29 


30. 


. 11 




0. 


•44 


4245 


11. 


■ 52 




2. 


•95 


65 -59 


62. 


•13 




3- 


.61 


69.13 


54- 

















T3 4> 




41 > 




"O C 




-a— ' 




< 


89 




52 


49-33 


29 




33 


73-38 


29 




62 


4.91 


33 




23 


21-55 



5 

32 

6 

33 

1 

3 

4 

13 

Under certain conditions, however, sucrose may be ab- 
sorbed into the system without being first inverted. When 
excessive quantities of a sugar are ingested, absorption takes 
place more rapidly than digestion, i. e., the assimilation limit 
is exceeded. Sucrose which gains access to the blood stream 
in this way is not utilized, however, for it immediately 
appears in the urine. This fact has also been proved by the 
injection of sucrose into the blood when it is excreted almost 
quantitatively. The appearance of sugar in the urine under 
such conditions is termed "glycosuria." An alimentary 
glycosuria may occur upon the excessive ingestion of any of 
the readily absorbable sugars. The quantity which may 
be ingested at one time without causing glycosuria is a 
rather definite quantity for each individual. The following 
are average figures: 

Grams. 

Lactose 120 

Cane-sugar 150-200 

Levulose 200 

Glucose 200-250 



212 CARBOHYDRATE-RICH FOODS 

When the ingestion of a sugar is distributed over long 
periods of time and particularly when it is taken with other 
food, greater quantities than these can be given without 
causing glycosuria. Taylor has suggested that the assimi- 
lation limit of glucose is not as definite a quantity as formerly 
supposed but that it depends upon the capacity of the indi- 
vidual to retain it without regurgitation. 

Cane-sugar, when taken in concentrated solution, has a 
disturbing effect upon the digestive processes. These dis- 
turbances are likely to arise from the ingestion of candies or 
sweet syrups except when accompanied by food or sufficient 
water. The effect has been shown to be a direct irritation of 
the gastric mucosa due to the rapid withdrawal of water, 
causing inflammation and excessive secretion of mucus and 
a highly acid gastric juice. The repeated irritation of the 
stomach may lead to serious gastric disturbances. Investi- 
gations have shown that with too large an ingestion of sugar 
(120 grams) the emptying of the stomach is delayed. In- 
vert sugar does not have as pronounced an effect upon the 
digestive processes as sucrose. 

Since sugars are not absorbed in the stomach, when their 
passage is delayed fermentation often takes place. The 
products of such fermentation vary — there may be lactic, 
butyric, or alcoholic "fermentation" according to the condi- 
tions which exist. Lactose has been shown to be less likely 
to give rise to fermentation. 

Sugar is the most concentrated form of carbohydrate food, 
for, in the form in which it is usually ingested it contains 
very little water. For this reason and because they are 
easily digestible and assimilable sugars are valuable when it 
is desired to supply food for the performance of work involv- 
ing a sudden outburst of effort; they become available to 
the tissues in a comparatively short time. Experiments with 
soldiers have shown that they are able to perform a greater 
amount of work without fatigue after the ingestion of sugar 
than without it. Since continued effort is accompanied by 
a depletion of the carbohydrate stores, it is necessary, when 
sugar is being taken for an increase of efficiency, to ingest 
it at intervals during the whole period. The fact that sugars 
are completely absorbed is of importance in the construc- 
tion of a diet in which it is desired to supply the energy 
requirements without producing a large fecal mass. 

Valuable as sugar is in certain cases, from a dietetic stand- 
point there is a certain danger in its use. Von Bunge has 
pointed out that the excessive use of sugar in the diet is 
likely to lead to a decrease in the ingestion of vegetable foods 



STARCH 213 

and to a consequent failure to obtain the inorganic elements, 
such as iron, calcium, phosphorus, etc., which are necessary 
for continued good health. The average diet has been shown 
to be comparatively low in these food constituents and any 
tendency to lower the quantity taken is to be guarded against. 

STARCH 

Starch is the principal form of carbohydrate in the food of 
man. It is the form in which the plant stores the soluble 
carbohydrate formed in the processes of photosynthesis 
against the future demands of the embryo or plant itself. 
It is a member of the group of carbohydrates designated as 
polysaccharides. A starch molecule is composed of a num- 
ber of molecules of glucose which have been united into a 
complex structure in which one molecule of water has been 
removed in the union of two molecules of glucose. 

Upon digestion (hydrolysis) starch is broken down into 
simple compounds — soluble starch, dextrin, maltose, glu- 
cose — according to the nature and intensity of the digestive 
process. The final product, glucose, is absorbed and used 
in the body or synthetized into a compound, glycogen, Avhich 
is similar in structure and serves as a reserve carbohydrate 
to the same end in the animal economy that starch does in 
the plant. In the plant, starch is stored in the form of fine 
grains or granules. These consist of alternate layers of 
particles of starch and of cellulose, a more dense and com- 
plex compound similar to starch, arranged in concentric 
rings. The shape of the granule and arrangement of the 
rings is characteristic of the plants in which they are formed. 
The microscopic appearance of the starch granule thus be- 
comes a valuable means of determining its origin and of 
detecting the adulteration of foods. 

Raw starch is insoluble in cold water. Under the in- 
fluence of heat (or acids) it takes up water, becomes hy- 
drated, swells, and becomes semitransparent, forming an 
opaque solution. This is not a true solution but one in which 
the starch particles are suspended in water — a colloidal 
solution. Careful treatment of starch with acids gives a 
partially hydrated product known as soluble starch, the dried 
form of which is soluble — a colloidal solution — in cold water. 
The hydration of starch under the influence of heat and in 
the presence of water causes the starch grains to swell and 
rupture the surrounding cellulose layers. This is the object 
sought in the cooking of vegetables. 

Dextrin is one of the first products of hydrolysis of starch, 
formed by the action of enzymes (digestion), of acids, or of 



214 CARBOHYDRATE-RICH FOODS 

heat. Although it still retains the complex structure of 
starch, it is more soluble in water. The carbohydrate of 
the crust of a loaf of bread is composed largely of soluble 
starch and dextrin formed during the baking process. 

The readily soluble and diffusible products of the hydroly- 
sis of starch, maltose and glucose, have already been consid- 
ered in our discussion of sugars. 

Starch itself is readily digested and absorbed. Glucose is 
the end-product of its digestion — the form of carbohydrate 
present in the blood stream. The digestion and absorption 
of starch extends over a considerable length of time being 
delayed by the associated indigestible cellulose. The result 
is that starchy foods yield glucose to the body over a much 
longer period of time than those containing soluble carbohy- 
drates, sugars. This is in most cases an advantage, particu- 
larly where severe muscular work is to be performed. The 
gradual absorption of the carbohydrate keeps the body con- 
tinually supplied with the most efficient food for the per- 
formance of work yet without depleting the store of glyco- 
gen before the next meal. 

The digestibility of the various prepared foods, particu- 
larly bread and potatoes, will be discussed later (pp. 223 
and 226). 

GRAINS AND THEIR PRODUCTS. 

This group of foods includes the seeds of various plants 
such as barley, buckwheat, corn or maize, oats, rice, rye, and 
wheat, and the products manufactured from them. Grains 
are harvested in the partially dried state and contain, there- 
fore, a lower percentage of water (10 to 12 per cent.) and a 
higher percentage of carbohydrate, protein and fat than the 
fresh grain. Starch is the predominating food-stuff (65 to 
75 per cent, of the dried grain). Small quantities of sugar 
and cellulose are present. The protein content is rather 
high (10 to 12 per cent.) and a number of different kinds are 
present. The predominating proteins, such as the alcohol- 
soluble protein, gliadin, and the glutelin, glutenin of wheat, 
are of a different type from those found in flesh foods. The 
nutritive value of vegetable proteins has been discussed 
(p. 144). The fat content of grains may be rather high, oats 
and corn contain as much as 8 per cent. ; the values average 
between 0.5 and 8 per cent., according to the kind of grain. 
The fat of the grains has a low melting-point and exists as 
an oil. Approximately 2 per cent of ash is present in grain. 
This is distributed chiefly in the outer layers of the kernel 
and the germ. The tables on page 215 give the composi- 



GRAINS AND THEIR PRODUCTS 



215 



tion of the various whole grains and of the flours prepared 
from them. 

Composition of Various Whole Grains as Marketed by the Farmer. 







Protein 




Carbo- 








Water, 


(NX6.25), 


Fat, 


hydrate, 


Fiber, 


Ash, 




per cent. 


per cent. 


per cent. 


per cent. 


per cent. 


per cent. 


Barley 


IO.85 


11.00 


2.25 


69 -55 


3-85 


2.50 


Corn . 


10-75 


IO.OO 


4-25 


71-75 


i-75 


1.50 


Oats . 


10.06 


12.15 


4-33 


57-93 


12.07 


3-45 


Rye . 


IO.50 


12.25 


1.50 


71-75 


2. 10 


1.90 


Wheat 


IO.60 


12.25 


i-75 


7125 


2.40 


i-75 



Composition of Prepared Cereals. 



Barley, pearled . 
Buckwheat flour 
Cornmeal, granular 
Oatmeal . 
Rice .... 
Rye flour . 
Wheat flour . 



11. 9 
13-6 
12.5 
7-3 
12.3 
11. 4 
12.0 



X 



10.5 
6.4 
9.2 

16. I 

8.0 
13-6 
11. 4 



2.2 
1.2 

i-9 

7.2 

03 
2.0 
1 .0 



>> 4J 

s: u 

O 
72 " 

77 
75 
67 
79 
7i 
75 



£ 

6-5 
0.4 
1 .0 
0.9 
0.2 
1.8 
0-3 



< 

2.6 

0.9 

1.0 

1.9 

0.4 

i-5 

0-5 



1603 

1577 

1620 
1811 

1591 
1626 

1610 



° .a 

K> O 

E73 

03 (J 

6 
28 

29 

28 

25 
29 

28 
28 



With few exceptions the grains are rolled or milled before 
they are used in the preparation of food. In the various 
processes certain portions of the grain are removed, particu- 
larly the outer layers of the kernel and the germ. The 
accompanying data related to the polishing of rice gives the 
important changes in chemical composition during milling. 

Chemical Composition of the Honduras Type of Rice after Various 
Milling Processes of Modern Rice Mills. 1 

Constituents (per cent.). 



Rough rice . . . 11 .27 
After removal of hulls . 12.32 
After removal of bran and 


5-40 
1. 18 


1.58 
I.79 


8.67 
O.99 


7.48 
8-57 


5-90 

2.42 


8-43 
9.78 


6.65 

2-75 


most of the germ . . 12.56 
After further removal of 


0-53 


0.40 


0-39 


7-79 


1 .90 


8.91 


2.17 


bran (pearling) . . 12.50 
After polishing . . . 1 1 . 89 
Coating 12.02 


0.47 
0.36 
0.40 


0.28 
0.25 
0.21 


0.30 
0.30 
0.26 


7.88 
8.06 

7-75 


i-53 
1.80 
1.66 


9.00 

9-15 

8.81 


i-75 
2.04 

1.88 



Total loss 2 66.00 85.00 73.00 10.00 32.00 10.00 32.00 

bulletin 330, U. S. Dept. Agr., 1916. 2 0n a moisture-free basis. 



216 CARBOHYDRATE-RICH FOODS 

Barley. — Barley is not used extensively for human food 
in this country. As "pearled barley," prepared by remov- 
ing the germ and the greater portion of the bran, it is used 
in soups. Barley water, prepared from "patent" barley 
flour, is used in infant feeding and in the diet of the sick 
room. "Patent" barley flour is finely ground pearl barley 
or barley which has been more thoroughly polished than 
pearl barley. 

Buckwheat. — Buckwheat, although ordinarily classed with 
the cereals, does not belong with them according to its 
botanical classification. Its use is confined chiefly to the prep- 
aration of pancakes, a hot breakfast cake. In the prepara- 
tion of buckwheat flour the outer covering is removed and 
the remaining portion rolled and bolted as in the prepara- 
tion of wheat flour. A rather coarse bolting cloth is used 
which permits a certain amount of the middlings (see flour) 
to pass through. A white grade of flour, bolted over a finer 
cloth, is poorer in protein and fat. Buckwheat is rich 
in "gluten" the water-insoluble, elastic protein mixture 
which is the basis of a batter capable of considerable expan- 
sion; thus giving a light cake when baked. 

Corn. — Indian corn or maize differs in composition from 
the other grains with the exception of the oat, in that it has 
a high percentage of oil. Corn products are not readily leav- 
ened because of their low gluten content; wheat flour is 
often added to rectify this defect. Corn and corn products 
show the same digestibility as other grains. There are a 
number of varieties of corn. From a dietetic stand-point 
distinctions are made among them chiefly on the basis of 
their use for food: the variety used for cornmeal flour or 
hominy is field corn; for "popping," popcorn; for use in 
the green state, green or sweet corn. Field corn is harvested 
in the semidry state ; it is marketed for human food as corn- 
meal, corn flour, hominy, and corn starch. 

Cornmeal or corn flour is prepared from the whole grain. 
"Old process" cornmeal is made by grinding the entire 
kernel and then separating the larger particles of bran with 
a sieve; this method gives a flour containing the germ and 
a certain amount of bran in addition to the starchy portion 
of the kernel. This product is rich in oil and protein. It 
is difficult to keep such meal, for the oil tends to become 
rancid. By more careful milling and bolting both the germ 
and bran are removed, yielding a product which is low in 
protein, ash, and particularly oil. This flour may be kept 
for a longer time than the "old process" cornmeal without 
becoming rancid. But the advantage is gained at the ex- 
pense of nutritive value and accessory substances. 



GRAINS AND THEIR PRODUCTS 217 

Yellow and white cornmeal are prepared from yellow and 
white varieties of corn respectively. Any preference shown 
for one or the other of these meals is a matter of taste, for 
there is essentially no difference between them. 

Corn starch is also prepared from maize. In its prepaia- 
tion the corn is steeped in warm water; the swollen grain is 
passed through coarse mills to disintegrate the kernel with- 
out breaking the germ; the germ is removed by a process of 
differential sedimentation in which the oily germ floats off 
at the top while the starch granules and other particles settle 
to the bottom of the separator; the sedimented starch gran- 
ules and associated hulls are reground and passed over a 
fine sieve to remove the hulls, and the starch finally purified 
by fractional sedimentation. Purified starch is sold as such 
or after being hydrolyzed with acids and steam under pres- 
sure, as glucose (p. 209). 

Green or sweet corn is characterized by its high sugar con- 
tent. It is eaten in the green state, hence its place in the 
diet is with succulent vegetables. Large quantities of sweet 
corn are canned, thus making it available throughout the 
year. 

Oats. — Oats, like corn, have a high fat content. The 
products prepared from oats usually contain the whole ker- 
nel and are therefore highly nutritious. The use of oatmeal 
by the Scotch has won for it a reputation as a stimulating 
and muscle-building food which is perhaps overestimated in 
comparison with other grain products of a similar character. 
Oat preparations do not leaven readily, since little gluten is 
present. Oatmeal is used largely in the preparation of por- 
ridges and to a smaller extent in bread and cakes. Because 
of the presence of the germ in oat products the percentage 
of purine bases is higher than in products prepared from the 
other cereals in which the germ is removed; for this reason 
they are excluded from a purine-free diet. Studies of the 
digestibility and availability of oats show them to be fully 
as well utilized as bread. 

Rice. — Rice is particularly rich in carbohydrate. It is 
used among certain people as the principal constituent of 
the diet, which is therefore deficient in protein and fat. The 
lack of protein accompanying a rice diet has been assigned 
by certain investigators as the cause of the inferior physical 
and mental development of these races. 

Rice is supplied in three forms: unhulled; " cured," free 
from the husk but still retaining the bran; and polished. 
The polished rice is sometimes coated with talc, paraffin or 
glucose to improve its appearance. In the processes of pol 



218 CARBOHYDRATE-RICH FOODS 

ishing the outer layers of bran are removed and in so doing a 
large portion of the mineral matter, particularly phosphorus, 
is lost. In polishing rice some important dietary consti- 
tuents (accessory substances) are also removed. People 
who use polished rice as the major constituent of the diet 
tend to develop beriberi, a disease which affects then ervous 
system. The ingestion of unpolished rice or the addition 
of foods containing the accessory food substances will cure 
beriberi. 

Rice is as readily and thoroughly digested as other grains. 
The small amount of cellulose it contains makes it a desirable 
food when the fecal residue is to be kept as low as possible. 
This applies particularly to polished rice. Because of the 
low protein and fat content it is advisable to eat protein- 
rich foods, such as eggs, cheese, and milk, with it. Vege- 
tables should be used with rice, particularly with polished 
rice, because of its low content of ash and accessory food 
substances. 

Rye. — Rye is used extensively in the preparation of bread. 
In composition it closely approaches wheat. Its proteins 
are in slightly different proportions; it has considerable pro- 
tein corresponding to the gliadin of wheat, but the other 
constituent of gluten, glutenin, is lacking. Bread made 
from rye flour is darker, the texture is more dense, and it 
contains rather more nourishment than wheat bread. The 
digestibility of rye bread is approximately equal to that of 
white bread. Bread made from flour from which the bran 
is not removed is not as thoroughly digested as the bolted 
flour. 

Wheat. — Wheat is used more extensively in the human 
dietary than any other grain. Chemical analysis does not 
indicate any particular superiority of wheat over other 
grains, nor is it found to be more digestible. It is the ap- 
pearance of the prepared product and the ease with which 
it may be leavened that makes wheat prized above the other 
grains. The fact that wheat flour is comparatively rich in 
the water-insoluble proteins present in the gluten, the alcohol- 
soluble gliadin and the alkali-soluble glutenin, makes it the 
preeminent bread-making grain. For the elastic adherent 
mixture, gluten, stretches and holds the expanding bubbles of 
gas produced by the leavening agents. It is the coagulation 
around these bubbles which gives to bread the porous structure 
in the baked product. With wheat or its products as the basis, 
the addition of various substances enables the housewife 
to prepare an endless variety of dishes, and thus use this 
valuable food without creating a distaste for it because of 
the monotony of the diet. 



GRAINS AND THEIR PRODUCTS 219 

In spite of its general adaptability to variety in prepara- 
tion wheat is consumed largely in one form, bread. Rye is 
the only other grain which approaches wheat in its bread- 
making properties. Rye bread is, however, a less attractive 
product for it is darker and slightly more sticky than wheat 
bread. 

Wheat is seldom eaten without a certain amount of me- 
chanical preparation and modification. The majority of the 
wheat is consumed in the form of products made from flour. 
The crushed or whole kernel is often used as a breakfast food 
after it has been swollen and the starch partially cooked by 
boiling. A recent preparation has been put on the market 
in which the whole wheat kernel is subjected to pressure, 
heated, then allowed suddenly to expand, producing a change 
in the structure similar to that obtained in popped popcorn. 

Flour is prepared. by a process of grinding and sieving by 
which the kernel is pulverized and the outer coverings or 
bran and the germ are separated from the inner portion, 
which is rich in starch and gluten. Formerly the wheat was 
ground in one process and the resulting products sifted and 
graded according to their fineness of division. This gave 
three general grades: white flour (finest), middlings (which 
contain some fine particles of the coarse outer material) and 
bran. Middlings obtained from the roller process differ 
from the above in that they contain very little bran. The 
present method is to crush the grain between a series of 
rollers which reduce the size of the particles gradually until 
the desired texture is obtained. Between the different sets 
of rollers are sieves to separate the finely divided flour from 
the coarser bran and germ. Early in the rolling process a 
white flour poor in gluten, called "break" flour is separated; 
as the grinding becomes finer more and more of the gluten- 
rich flour with a yellowish color, or the middlings is obtained. 
A mixture of these two general classes of flour, "breaks" 
and middlings give a flour containing the proper amount of 
gluten for bread-making. The highest grades of flour are 
known as "patent," "standard patent flour," "straight 
grade flour," "first clear." The lower grades of flour are 
designated "second clear," "baker's flour" and the lowest 
grade is called "red dog." The highest grades of flour are 
light in color and contain more gluten and show a better 
granulation than the lower grades. In the latter, the pro- 
tein content is higher, but the gluten is less elastic and not 
as satisfactory for bread-making purposes. The best test 
of a good flour is its baking properties. 



220 



CARBOHYDRATE-RICH FOODS 



Analysis of Wheat and the Products of Roller Milling (United 
States Department of Agriculture). 







Protein 




Carbo- 






Water, 


(Nxs.7), 


Fat, 


hydrate, 


Ash, 


Milling products. 


per cent. 


per cent. 


per cent. 


per cent. 


per cent 


First patent flour . 


10-55 


II.08 


I .15 


76.85 


0.37 


Second patent flour 


IO.49 


II. 14 


I.20 


76.75 


O.42 


First clear grade flour . 


IO.13 


13 -74 


2.20 


73 13 


0.80 


Straight or standard patent 












flour . ' . . . 


IO.54 


11.99 


I. 6l 


7536 


O.50 


Second clear grade flour . 


IO.08 


15-03 


3-77 


69-37 


i-75 


"Red dog" flour 


9.17 


18.98 


7.00 


61-37 


3-48 


Shorts 


8-73 


14.87 


6-37 


65 -47 


4-56 


Bran 


9-99 


14.02 


4-39 


65 -54 


6.06 


Entire wheat flour . . . 


10.81 


12.26 


2.24 


73 67 


1.02 


Graham flour .... 


8.61 


12.65 


2.44 


74-58 


1.72 


Wheat ground in laboratory 


8.50 


12.65 


2.36 


74.69 


1.80 


Germ 


8-73 


27.24 


11.23 


48.09 


4-71 



There are a number of varieties of wheat: spring, winter, 
soft, and hard. By the use of these and by different methods 
of manipulation a number of grades of flour is produced 
which vary chiefly in their gluten content. In baking these 
differences assume more or less importance. From a nutri- 
tive point of view, however, it is the relative proportion of 
the inner portion of the kernel, bran, the outer covering, and 
the germ which is of importance. 

Certain grades of flour have distinctive names under which 
they are sold in commerce. Graham flour is composed of the 
carefully ground, unbolted entire wheat kernel. As such it 
contains all the constituents of the wheat, the bran, the 
germ, and contents of the endosperm (starch and gluten). 
This flour derives its name from Sylvester Graham who ad- 
vocated the ingestion of the whole wheat for both economi- 
cal and dietetic reasons. The greater cellulose content of 
the bran renders bread from such flour less digestible. The 
added intestinal irritation, the bulk derived from the par- 
ticles of indigestible bran, and certain substances present 
in the bran and germ have mild laxative properties. 

Entire wheat flour is made of wheat from which the greater 
part of the outer covering, or bran, has been removed. It 
contains the germ with its added fat and protein content in 
addition to the usual constituents of flour. The increased 
nutritive value protein — fat and ash — of the flour is of econo- 
mic importance. 

Gluten flours are prepared by removing the greater part 
of the starch from ordinary flour and are supplied in various 
grades, according to the quantity of gluten present. They 
are of particular value as food for diabetics. Gluten flours 
are discussed further in connection with diabetes. 



GRAINS AND THEIR PRODUCTS 221 

Bread. — The term bread is usually applied to the baked, 
leavened preparation of wheat flour. It may, however, 
include similar preparations of all forms of finely divided 
grains, such as rye bread or corn bread. When the added 
ingredients used with flour assume importance with regard 
to flavor and texture, the mixture is no longer distinguished 
as bread. Thus sugar, butter, eggs, milk, spices, are used 
with flour in the preparation of cakes, puddings, and pastries. 

Bread in the sense ordinarily used is a combination of 
white flour, water, salt, and yeast which have been leavened 
as the result of the growth of the yeast. In this process 
carbon dioxide is formed and the mixture " rises," assuming 
a spongelike structure. This "sponge" is kneaded with the 
addition of flour, divided into appropriate masses, permitted 
to rise again and, at the proper time, baked. In the process 
of baking heat causes a further expansion of the carbon 
dioxide and air and by coagulating the proteins retains the 
sponge-like structure. Various changes take place in the 
chemical composition of the flour during the leavening pro- 
cess. A certain amount of sugar is converted into carbon 
dioxide and alcohol; during baking there is a loss of water 
and fat, the protein is coagulated, the starch grains are 
broken, and at the outer surface particularly starch is con- 
verted by dry heat into soluble starch and dextrin. The 
partial caramelization of the starch and dextrin produces 
the delicate brown color of a well-baked loaf. 

Leavening may be accomplished in a number of ways — 
with yeast (enzymatic) which is supplied in both moist (com- 
pressed yeast) and dried condition; by mechanical incor- 
poration of air; or by the evolution of gas as the result of 
chemical action (baking powder). When yeast is used the 
carbon dioxide is produced at the expense of the constituents 
of the flour, the starch is partially converted into simpler 
products in addition to alcohol, and certain amounts of 
organic acids, such as lactic or acetic, which in quantity 
are said to injure the flavor of bread. 

The simplest form of aeration with mechanical incorpora- 
tion of gas is that produced by "beating up" a mixture of 
flour and water. The entrapped bubbles of air swell and pro- 
duce, when baked, porous though rather dense biscuit or 
bread. Unleavened bread is used in certain religious festi- 
vals. In the commercial preparation of bread, water satu- 
rated, under pressure, with gas is sometimes mixed with 
flour. When the pressure is released the dough swells; it is 
then baked. This is called aerated bread. 



222 CARBOHYDRATE-RICH FOODS 

Baking Powders. — Baking powders will leaven dough 
more quickly than will yeast, in a few minutes, instead of 
in six to ten hours. All baking powders depend in principle 
upon the interaction between a carbonate and an acid. 
Sodium bicarbonate (saleratus or baking soda) is the most 
common source of carbon dioxide. The old method of mak- 
ing certain breads with sour milk and soda often resulted in 
a semifailure because of the varying degrees of acidity of 
the milk. The baking powders now supplied have the acid 
and alkali so balanced that there is complete neutralization. 
Preparations vary chiefly in the nature of the acid consti- 
tuent or its equivalent; thus we have the "tartrate" (tar- 
tar), acid potassium tartrate or tartaric acid powders; the 
phosphate (calcium acid phosphate) powders, and the alum 
powders (a sulphate of aluminum). These salts when 
mixed with bicarbonate are relatively inert in the dry state 
but in the presence of water react readily to yield carbon 
dioxide. 

There are certain objections to the use of baking powders 
in that the salts resulting from their reactions may be deleter- 
ious to the health through their action on the system in gen- 
eral or to their laxative effect. While it is certain that ex- 
cessive doses of these salts are harmful it is difficult to deter- 
mine whether or not small amounts, such as are ingested in 
breads, are detrimental. 

Rolls, Biscuits, Muffins, etc. — Rolls are similar to bread 
except that they usually contain more added fat in the form 
of lard or butter and sometimes more sugar. They differ 
little in composition from bread. In baking they are ordi- 
narily made into small loaves or " rolls" and have more crust 
in proportion to their size than bread. Such breads are 
often used while hot or warm. 

The ordinary baking powder biscuit differs from the roll 
in that it is leavened with baking powder and contains 
more shortening, as lard or butter. The effect of the short- 
ening is to render the gluten less tenacious. Biscuits are, 
therefore, readily broken into pieces when hot. 

Muffins are similar to biscuits; they usually contain egg 
in addition to other ingredients. 

Rolls, biscuits and muffins are often referred to as indiges- 
tible. This indigestibility is ascribed in part to the added 
fat and in part to the fact that since they are served hot, 
they are eaten rapidly and without sufficient mastication, 
thus yielding a sodden mass which does not pass readily 
from the stomach. Experiments have shown the relative 
availability of the protein, fat, and carbohydrate of these 
foods to be fully as complete as those of bread. 



GRAINS AND THEIR PRODUCTS 



223 



Biscuits, Crackers. — The term biscuit is used commonly 
to designate the hard, dry breads baked in thin layers and 
prepared with the addition of little or no baking powder. 
These are sold in various forms depending upon the ingre- 
dients used in their manufacture. They are held to be very 
digestible, no doubt because of their dryness and to the com- 
plete salivation and mastication necessary in eating them. 

Cakes. — Cakes are sweetened breads in which eggs, milk, 
flavoring and spices and considerable shortening, such as 
butter and lard, are used. They are very "rich" foods in 
that they contain more fat and protein than the breads. 

Breakfast Foods. — Certain specially prepared grains are 
sold as breakfast foods. These are usually patented prepara- 
tions. Among them will be found representatives of all the 
more important grains. The changes produced are chiefly 
of a mechanical nature associated with a certain amount of 
chemical change resembling the natural processes of diges- 
tion. The changes are in general of a fermentative nature, 
such as those produced by the action of malt or yeast and the 
action of heat upon either the moist or dry grain. Condi- 
ments, such as sugar and salts, are sometimes added. Those 
foods which are cooked are sold for direct consumption; 
the others must be subjected to prolonged cooking before 
they are ready for the table. 

Macaroni. — Macaroni is a preparation of a highly gluten - 
ous wheat flour and water. It is molded into various forms 
and sold under different trade names, as spaghetti, macaroni, 
and noodles. A special type of wheat, durum wheat, is 
used. The relative composition of macaroni will be found 
in the accompanying table. 

The composition of some wheat preparations is given in 
the following table: 

Composition of Typical Wheat Products. 







.s ° 

Z 


a 




a. 

u 


u 
<u 


■i-s 

T, O 


m O 






o. 


<3 


u 


p 


03 

< 






Breakfast food: 


















Cracked Wheat . 


10. I 


II. I 


1-7 


75-5 


i-7 


1.6 


1635 


28 


Shredded Wheat . 


8.1 


10.5 


1.4 


77-9 


1-7 


2. 1 


1660 


27 


Macaroni 


10.3 


13-4 


0.9 


74.1 




i-3 


1625 


28 


Rolls, Vienna 
Bread: 

White . . . . 


37-i 


8-5 


2.2 


56.5 


0.4 


1 . 1 


1270 


36 


35-3 


9.2 


1-3 


53- 1 


0.5 


1 . 1 


H82 


38 


Whole wheat . 


38.4 


9-7 


0.9 


49-7 


1.2 


I.-3 


III3 


41 


Crackers, soda . 


5-9 


9.8 


9-i 


73- 1 


0.3 


2. 1 


187.S 


24 


Cake, cup 


15-6 


5-9 


9.0 


68.5 


0.3 


1.0 


1716 


26 



224 CARBOHYDRATE-RICH FOODS 

The digestibility and nutritive value of bread, particu- 
larly the comparative digestibility of white bread and the 
whole wheat or Graham bread assumes considerable econo- 
mic importance with regard. to the diet of the poor and there 
has been a great deal of controversy over the question. 
Comparative studies of the two forms of bread have demon- 
strated a lower digestibility of the protein and carbohydrates 
of entire wheat and Graham flours. 

Celluloses. — Celluloses form a large portion of the cell 
wall of plants. They are polysaccharids having a more 
complex structure than the starches". Celluloses differ ac- 
cording to whether they are composed of glucose or some 
other sugar, as pentose or galactose. These carbohydrates 
are very insoluble in water and more difficult to hydrolyze 
than starch, and are practically indigestible for man. It is 
the indigestibility of the celluloses which makes vegetable 
and fruits a valuable means of adding bulk to the intestinal 
mass with the resultant stimulation of peristalsis. Cellu- 
lose is also largely responsible for the low utilization of vege- 
table foods. 

Hemicelluloses differ from true celluloses in that they are 
hydrolyzed by dilute acids. Of this class the sea-weed, agar 
agar and Iceland moss are of dietetic and therapeutic import- 
ance. Because of their comparative indigestibility and their 
ability to absorb and hold water they yield a soft fecal mass 
which may be easily evacuated. 

Potatoes. — The true, " Irish," potato, as well as the sweet 
potato, is used to a large extent as one of the important 
sources of carbohydrate. We will therefore discuss these 
foods here, although they possess properties which might 
place them with the succulent vegetables, more valuable for 
their salts and water. Bananas are, from a nutritive point 
of view, comparable with potatoes; they are, however, ordi- 
narily classed with fruits. 







Composition. 
























03 






u 
u 

<u 

a 




.5 ° 


(3 

V 




V 

si 


<v 


p. 


a 


u 


u 

O 








u 
<v 




a 


u 




o< 


> s 

•31 O 


oa.2 

GA 






a 


fa 


O 


•Q 

£ 


j5 

w 

< 


fa 


§0 

u 




Potatoes: 


















Irish . 


. 78-3 


2.2 


0. I 


I8.4 


0.4 


1.0 


378 


120 


Sweet 


. 69 . 


1.8 


0.7 


27.4 


1.3 


1. 1 


558 


81 


Bananas 


• • 75-3 


1-3 


0.6 


22.0 


1 .0 


0.8 


447 


101 



GRAINS AND THEIR PRODUCTS 225 

The chemical composition of potatoes varies somewhat 
according to the different varieties, and to the portion of the 
country in which they are grown. The average potato con- 
tains 1 8 to 20 per cent, carbohydrate (largely starch); 2 to 
2.5 per cent, protein; practically no fat — 0.1 per cent.; and 
75 to 80 per cent, water. The greater proportion of the 
carbohydrate present in potatoes is starch; but there is also 
a small proportion — 0.3 to 0.2 per cent, of sugars and glu- 
cose. The sugar content of young or early and old, sprouted 
potatoes is greater than that of the mature potato. The 
tuber receives carbohydrate as glucose and converts it to 
starch; later as the potato sprouts the starch is reconverted 
into glucose for the use of the growing shoots. The protein 
of potatoes is usually expressed as the nitrogen value times 
6.25. We know that in the case of the potato this does not 
entirely represent protein, for there is a considerable quan- 
tity of non-protein, nitrogenous-containing material, parti- 
cularly asparagin. The ash of potato contains considerable 
quantities of calcium, phosphorus and iron. The total ash 
is predominantly basic. 

Potatoes are rich in the water-soluble accessory substances 
(vitamines). The use of potato water as an anti-scorbutic 
has been suggested for infants in place of the more expensive 
orange juice. 

The sweet-potato plant does not belong to the same bo- 
tanical family as the Irish potato. This tuber resembles 
the latter, however, in its general chemical composition and 
is usually associated with it dietetically. The sweet potato 
is roughly similar in composition to the Irish or white potato; 
it contains a little less water — averaging 70 per cent.— and a 
slightly higher percentage of starch, sugar and protein, aver- 
aging 24 per cent., 5 to 8 per cent., and 1 per cent., respec- 
tively. The effect of the storage of sweet potatoes is to in- 
crease the sugar content. The material designated as 
"sugars" is chiefly sucrose with a small amount of invert 
sugar (glucose and fructose). 

Because potatoes are an important source of mineral mat- 
ter it is essential to conserve this as much as possible. In the 
process of paring as much as 20 per cent, of the potato is 
lost; furthermore, a large proportion of the protein and 
mineral matter is in the layers beneath the skin. The skin 
tends to prevent the loss of protein and salts. Peeled pota- 
toes when soaked in water and then boiled in water lose a 
considerable proportion of their salt content, approximately 
ten times as much as when they are cooked without removing 
the skins. When they are baked or steamed the loss is 

15 



226 CARBOHYDRATE-RICH FOODS 

comparatively small. If the cooking is begun in hot water 
the loss of material is less than when the cooking is com- 
menced in cold water. 

Potatoes when properly cooked are quite digestible; ap- 
pioximately 92 per cent, of the carbohydrate and 70 per cent, 
of the protein is absorbed. They have been found to leave 
the stomach quite rapidly — more so than bread. The ease 
with which potatoes are digested varies with the mode of 
preparation. Boiled or baked mealy potatoes pass more 
readily from the stomach than waxy potatoes or potatoes 
which have been fried or prepared with fatty substances as 
in salads. Finely divided pieces of potatoes pass out of the 
stomach more readily than larger pieces. The low fat con- 
tent of potatoes indicates the addition of fatty substances 
after they are cooked when they are used as the principal 
source of food. 

Because of the low cost of potatoes they have been advo- 
cated as the chief article of diet in some countries. There 
is a certain amount of objection to this because of the quan- 
tity which must be eaten to supply the necessary energy 
and protein — approximately 6.5 pounds or 3 kilos. Such 
quantities would contain a smaller proportion of protein 
than is deemed necessary by some. The energy value is, 
moreover, roughly a thiid that of white bread. Hindhede, 
of Sweden, who has advocated the adoption of a potato diet, 
has shown that the body may be maintained in perfect 
health over long periods of time on a diet of potatoes, milk, 
oleomargarine, green vegetables, and fruit, provided the total 
diet has an energy value in proportion to 3000 Calories for 
a man of 70 kilos (164 pounds). 



CHAPTER XIV. 
FAT-RICH FOODS. 

Fats are important in the diet in that they supply energy 
in a concentrated form and certain of them carry the fat- 
soluble vitamine. In general, organ fat as distinct from 
body fat is rich in fat-soluble A; thus butter fat, kidney fat 
and cod liver oil are valuable sources of this food factor. 
Beef fat is relatively poor in fat-soluble A, while in lard, and 
the vegetable fats it is practically absent. Considerations 
of the relative value of butter, and the hydrogenated vege- 
table fats, and the margarines must take these facts into 
consideration. 

Animal or plant fat is a mixture of true fats and lipins. 
The true fats are glycerol esters of fatty acids; they are 
named according to the acid from which they are derived by 
substituting "in" for "ic" of the name given the fatty acid, 
thus: Butyrin, olein, stearin, or tributyrin, triolein, tris- 
tearin for fats formed from butyric, oleic and stearic acids. 
Fats are widely distributed in the plant and animal kingdom 
and are one of the most valuable sources of energy to the 
body. Associated with fat are the lipins, or fat-like sub- 
stances related by composition and solubility. In their 
chemical constitution lipins may differ entirely from fats 
as cholesterol, or may be compounds of fat with other radi- 
cles as in the case of lecithin. The lipins are constituents of 
all cells and particularly of the highly organized nervous 
tissue. Our knowledge of their occurrence and functions 
is, however, very limited. 

The fats most commonly found in food are those derived 
from the saturated fatty acids, butyric acid, caproic acid, 
caprylic acid, capric acid, lauric acid, myristic acid, palmitic 
acid and stearic acid, and from the unsaturated fatty acids, 
oleic, linoleic, and linolenic acids. Of the saturated fatty 
acids, the first members, butyric and caprylic acids, are 
liquid at ordinary temperatures, while the others are solid: 
the melting-point increases with the complexity of the mole- 
cule. The unsaturated fatty acids and the glycerol esters, 
fats, are liquid at ordinary temperatures. 

Food fats are mixtures of these individual fats. Those of 
animal origin are composed largely of olein, palmitin, and 
stearin. The fluidity or solidity of any particular fat de- 



228 FAT-RICH FOODS 

pends upon the relative proportion of these. The more solid 
fats contain a greater amount of palmitin and stearin, while 
the softer fats contain more olein. 

The fat of various animals is more or less characteristic 
for each species. Warm-blooded animals have harder fat 
than cold-blooded animals, such as fishes; and of the land 
animals herbivora have, as a rule, harder fats than carni- 
vora. The composition of subcutaneous fat appears to be 
determined in part by the external temperature of the air 
surrounding the body. The facial fat of individuals exposed 
to the weather is richer in olein and has a lower melting- 
point than of those less exposed. The fat of those portions 
of animals which have a poor blood supply, such as the back, 
is richer in olein and has a lower melting-point than fat in 
other parts thoroughly warmed by the blood. The fat of 
beef animals has been found to become richer in olein with 
age, fatness, and nearness to the surface of the body. 

Butter contains a variety of fatty acids — all of those men- 
tioned above in the saturated fatty acid series and oleic 
and butyric acids. The latter acid, while not the most 
important from a quantitative point of view, is most char- 
acteristic. The vegetable oils contain more of the unsat- 
urated fat compounds than animal fats. 

Certain fats — milk fat and the fat of egg yolk in particu- 
lar — occur in a finely divided state or emulsion. Such fats 
are readily digestible because of the size of the fat particles 
and great surface exposed to the action of the digestive enzy- 
mes. Emulsification may be produced artifically by thor- 
ough agitation of fat with water or by the addition of pro- 
tein material, certain carbohydrates, gum tragacanth, or of 
soaps. Alkalis when added to fats form soaps which in 
turn aid in emulsification. Mayonnaise dressing, in which 
comparatively large quantities of oil are changed from the 
liquid state to a semi-solid form, is a case of emulsification 
in the presence of protein material. 

Fats are as easily digested and absorbed as proteins and 
carbohydrates. In the process of digestion and absorption 
they are emulsified and broken down into fatty acids and 
glycerol, absorbed into the intestinal wall and in part at 
least resynthetized into fat. The presence of fat tends to 
delay the passage of food from the stomach. The "indiges- 
tibility" of fatty foods in the sense of the "ease" of digestion 
is to be ascribed in part to this fact. The presence of fats 
in food, particularly of those having high melting-points 
which are not liquefied in the stomach at body temperature, 
tends to retard peptic and salivary digestion. Fats form a 
protective coating over the particles of protein and starch 



FAT-RICH FOODS 229 

and prevent their partial digestion, thus increasing the ex- 
tent of digestion necessary in the intestine. The effect of 
cooking foods in fat is to form a similar layer of fat over the 
surface of the food particles. This applies particularly to 
the ordinary process of frying, in which heavy fats are often 
used; cooking in deep fat results in the formation of an im- 
pervious layer on the outside of the food which prevents 
the further entrance of fat. The partial oxidation of fats 
which takes place in cooking, particularly in frying, leads 
to the formation of substances which may be irritating to 
the alimentary tract. 

The retarding action which fats exert upon the passage of 
food from the stomach has been found to be beneficial in the 
case of the relatively indigestible vegetables, for by subject- 
ing them to a more prolonged contact with the digestive 
juices their digestion is more complete. Vegetables to which 
a soft fat, such as butter, has been added, after cooking, 
have been found to be more thoroughly digested than those 
cooked in fat. Studies of the utilization of fat have shown 
that ordinary fats are readily absorbed, approximately 97 
per cent, of the ingested fat. 

Feces obtained from a fat-poor diet may contain more fat 
than is found in the food ingested. On a milk diet under 
normal conditions the fecal fat melts at 50 to 51 C, while 
the fatty acids of butter melt at 43 C. ; in diarrhea the fecal 
fat has the same melting-point as milk fat. These facts indi- 
cate that considerable fat is excreted or secreted into the 
intestines from the body in the process of digestion. 

The melting-point of fat affects its digestibility. Those 
fats whose melting-points are close to the temperature of the 
body are liquefied in the alimentary canal, readily emulsified 
and digested in the intestines, and show practically complete 
absorption. The more solid fats, are, on the other hand, 
emulsified with greater difficulty and their digestion is less 
complete. Certain fat-like substances, such as paraffin oil 
and lanolin, are not absorbed at all; it is for this reason that 
paraffin oils are used to relieve constipation. These facts 
have been brought out in the following table (Munk and 
Arnshink) : 

• Melting- Percentage 

point, loss in 

Fat °C. feces. 

Stearin 60 91-86 

Stearin and almond oil 55 10.6 

Spermaceti 53 31.0 

Mutton fat 50-51 9.2 

Mutton, fatty acids 56 13-20 

Lard 43 2.6 

Pork fat 34 2.8 

Goose fat 25 2.5 

Olive oil fluid . 2.3 



230 FAT-RICH FOODS 

Langeworthy and Holmes 1 compared the relative digest- 
ibility of butter, lard, beef and mutton fat when fed with a 
uniform mixed diet of blanc mange, wheat biscuit, fruit and 
sugar. In general the digestibility decreased with an in- 
crease in the melting-point of the fat. The following table 
contains data demonstrating this: 

Comparison of Digestibility and Melting-point. 

Coefficient of Melting- 
digestibility, point, 
Fat studied per cent. °C. 

Butter fat 97 32 

Lard 97 35 

Beef fat 93 45 

Mutton fat 88 50 

In the processes of metabolism both fat and carbohydrate 
are used chiefly in the production of energy. Their role in 
the structure of the body, while little understood, is highly 
important; this is particularly true of the lipins, lecithin and 
cholesterol, which are constituents of the outer surface of all 
cells. As a source of energy fats and carbohydrates may, in 
general, be used interchangeably. It seems necessary, how- 
ever, that a certain amount of carbohydrate be present in the 
food for the normal continuance of the metabolic processes. 
The entire absence of carbohydrate tends to produce certain 
disturbances, among which acidosis is the most prominent 
indication. The minimum quantity of carbohydrate needed 
is not known ; that it may be comparatively low is illustrated 
in the case of the Eskimo whose diet is essentially fat and 
protein and in which practically the only source of carbohy- 
drate is the glycogen contained in meat. 

Although carbohydrate appears to be indispensable in the 
diet, the presence of fat (lipins) is also essential. Studies of 
growing animals have shown that certain animal fats, e. g., 
kidney fat, egg yolk fat, butter fat, are more satisfactory 
than others or than plant fats for the continuance of growth. 
The advantage apparently does not reside in the purified 
fat itself, such as tristearin, or triolein for these are without 
effect. It is known that there are substances associated 
with fat which are important for growth and that the ab- 
sence of these from the diet result in pathological conditions. 
Such substances as the accessory food substances, " fat- 
soluble A" of McCullum, which the body apparently cannot 
synthetize and must therefore obtain them from the food 
are present and necessary. It is the absence of these sub- 
stances which in part explains the failure of some fats to 
promote growth. The necessary amount of natural fat 
required per day is not known — the minimum has been esti- 
mated at from 25 to 50 grams of fat per day. 

^U. S. Dept. Agr., 1915, Bull. No. 310. 



CREAM 231 

Fat is a much more concentrated food than carbohydrate 
or protein in the sense that it yields, because of its lower 
state of oxidation, a greater amount of energy for a given 
weight : 

Calories Calories 

per gram. per pound. 

Fat 90 4082 

Carbohydrate 4.0 1814 

It is therefore the most economical means available to the 
body for storing energy against future need. But not all 
the fat of the body comes from fat; it may be formed from 
carbohydrate (glucose). Protein yields complexes which 
may be built up into fat. 

Fat is present in the human diet in two forms: (a) that 
associated with the food as it occurs naturally and (b) that 
which has been extracted from the medium in which it was 
deposited — flesh, milk, fruits — and which is ingested as such 
or added to food in the process of preparation. Prepared 
fats are similar to the unextracted fats, for the processes of 
manufacture are essentially physical ones: the fatty sub- 
stance is separated from its surrounding medium by means 
of pressing, churning, or heat or a combination of these; 
very little chemical change takes place except perhaps in 
some forms of rendering or heating in which there is a par- 
tial hydrolysis and slight oxidation of the original fats. We 
shall therefore confine our discussion largely to the manufact- 
ured fats and oils, indicating occasionally the relative fat 
content of certain particularly fatty natural foods when dis- 
cussing the particular prepared fat which it would yield. 

Two types of fat-rich foods are obtained from milk: cream, 
in which the finely emulsified fat is concentrated by gravity 
or centrifugal force and which contains a small proportion 
of all the constituents of milk, and butter, in which the fat 
droplets are made to coalesce. Butter contains very little 
of the milk constituents other than the fat. 

CREAM 

Cream is obtained from milk in two ways, both depending 
upon the difference in specific gravity between the fat and 
the other constituents. Formerly milk was placed in a cool 
place for six or eight hours and the fat or cream permitted 
to rise to the top; it was then removed or "skimmed off." 
The separation of the cream from the milk is hastened by 
the use of a centrifuge or separator which throws the heavier 
portions of the milk, water, protein, insoluble salts and cells 
to the periphery from which it is removed while the lighter 



232 FAT-RICH FOODS 

fat is drawn off from the center. With the separator vary- 
ing concentrations of butter fat can be obtained in the 
cream. 

BUTTER 

Butter is obtained from cream by the process of churning, 
i. e., by mechanical agitation the natural emulsion of milk 
is destroyed and the fat droplets made to coalesce. This pro- 
cess is facilitated by the slight changes produced in the cream 
as the result of fermentation or souring. The crude butter 
collected in the process of churning is separated from the 
rest of the cream — the butter milk— washed and worked into 
the final product which we know as butter. The process 
of working removes most of the particles of curd remaining 
and the soluble constituents of milk. This gives pure, un- 
colored sweet butter. Salt is usually added to sweet butter 
to give it a flavor; it also acts as a preservative. The 
amount added varies according to the market for which it 
is intended — from o to 4 per cent. In salting a very good 
grade of sodium chloride is used. Salted butter is then 
worked to distribute the salt, to remove the excess of water, 
to press the particles of fat together into a compact mass, 
and to give it the texture characteristic of the butter of com- 
merce. 

The color of butter will vary according to the nature of the 
diet of the cow, for the coloring matter of the body fat and 
milk has been shown to be derived from the coloring matter 
of plants. Butter made from the milk of cows receiving cer- 
tain green foods is particularly rich in the yellow color com- 
monly associated with butter; thus butter made in the spring 
usually has a deeper yellow color than that made in the win- 
ter. To ensure a butter of uniform color throughout the 
year dairymen resort to the use of coloring matter. 

The presence of bacteria in butter is a matter of fully as 
great importance as their presence in milk. The processes of 
butter-making tend to increase the number of bacteria: 
centrifulgalization so generally employed for the separation 
of cream from milk tends to leave the bacteria in the cream 
and the conglomeration of the particles of fat in the process 
of churning results in a concentration of bacteria in the but- 
ter. The result is that butter often contains many more 
bacteria than the cream from which it is prepared. The 
souring of cream before its use in butter-making results in an 
accumulation of lactic-acid-producing bacteria with an ac- 
companying decrease in the rate of growth of certain other 
types. The Bacillus tuberculosis has been found in butter 



BUTTER 233 

prepared from milk containing this organism; cold storage 
does not result in the death of the bacillus. 

The following table gives the composition of American 
creamery butter: 

Per cent. 

Fat 82.41 

Water 13 .90 

Lard 2.51 

Curd , . 1. 18 

Vaiiation from these figures will occur, depending upon 
the process of manufacture. Dividing the samples of butter 
into classes according to the fat content, the following gen- 
eral variations were observed in the case of the data given 
above: butter fat 5.0 per cent., water 2.9 per cent., salt 1.74 
per cent., and curd 0.39 per cent. 

Butter fat is a mixture of the glycerides of various fatty 
acids with small amounts of lipoids — lecithin and choles- 
terol — and coloring matter. The relative proportions of 
these individual fats, or as they are usually expressed in 
analysis, "fatty acids," varies with the food, particularly 
with the fat content of the food, the individuality of the cow 
and stage of lactation. The taste and odor of butter is 
influenced by the food given the cow; garlic, for instance, 
gives to milk and butter a decided odor characteristic of the 
plant. 

The following table gives the distribution of the more im- 
portant fatty acids found in a particular sample of butter: 1 

Percentage of 
Acid. triglycerides. 

Dioxystearic 1.04 

Oleic 33-94 

Stearic 1.91 

Palmitic . . . .40.51 

Myristic 10 .44 

Laurie 2.73 

Capric 0.34 

Caprylic 0.53 

Caproic 2.32 

Butyric 6.23 

Butter fat is practically completely absorbed. The aver- 
age caloric value of butter, based upon an 85 per cent, fat 
content, is approximately 3500 Calories per pound or 7.7 
Calories per gram. 

Renovated Butter and Butter Substitutes. — When butter 
which has become rancid is treated to restore its sweetness 
the product is designated as " processed or renovated" butter. 
The rancid butter is melted, the curd and brine drawn off, 

1 Browne: Jour. Amer. Chem. Soc, 1899, xxi, 807. 



234 FAT-RICH FOODS 

the fat separated and aerated and then rechurned with milk 
or cream to restore the texture and flavor. Such butter is 
in many respects as satisfactory as the average grade of 
butter; it is not equal in quality to the better grades of 
butter. 

Oleomargarine. — A fat product prepared from various 
animal and vegetable fats and oils which resemble butter 
in its consistency is sold under various names, of which 
oleomargarine or margarine are the most common. Its 
manufacture is restricted by the government; a tax is levied 
against it, a fourth cent per pound for the uncolored product 
and ten cents per pound for oleomargarine artifically colored 
to resemble butter. Yet oleomargarine is a satisfactory 
substitue for butter; it is often more desirable than some good 
grades of butter. One objection to oleomargarine is that 
it is many times sold as butter with the intent to deceive. 
Containing as it does a higher percentage of stearin, we 
might expect to find oleomargarine less readily absorbed 
than butter; experience has shown, however, that the losses 
in digestion are nearly the same for the two products. But- 
ter is, however, in many ways a finer product and more 
palatable. It is much richer in the accessory substances or 
vitamines than oleomargarine and is from this point of 
view a much more desirable food. 

The materials used in the manufacture of oleomargarine 
are chiefly neutral lard, "oleo oil," and cotton seed oil. 
Neutral lard is prepared from the fresh "leaf lard" of the 
hog. This is ground up, worked with water, and rendered 
at a temperature of 40 to 50 C. Only a portion of the lard 
is removed from the fat. The product obtained is almost 
neutral in reaction and practically free from taste or odor. 
Oleo oil is prepared by a somewhat similar process. Fat 
from the abdominal cavity of beef or caul fat is thoroughly 
worked in water, chilled, the hardened fat ground up and 
finally rendered at a low temperature. The liquid fat ob- 
tained by this process is permitted to cool, when stearin and 
palmitin partially crystallize out. The fluid portion is 
pressed. out of the semisolid mass, run into cold water and 
allowed to solidify. This product is designated as "oleo" 
or "oleo oil. " The cotton seed oil used is especially prepared 
for the purpose. Cocoanut fat and peanut oil are also 
used. The nut margarines do not have the same biological 
value as butter or the oleomargarines, since they lack the 
fat-soluble vitamines. In the final stage of preparation 
the fats and oils are mixed in the desired proportion; the 
quantities of the various constituents used depends upon the 






VEGETABLE OILS 235 

market for which the oleomargarine is intended. For warm 
climates more of the oleo oil and lard are used than for cold 
climates. The properly mixed fats are then churned with 
milk or cream, or with an emulsion of milk and butter to 
give the flavor of butter to the product. This yields a coarse 
emulsion which, upon cooling, is washed, salted, and work- 
ed into the final product. The following is the composition 
of oleomargarine, given by Koenig, in per cent.: Water, 
9.07; fat, 87.59; nitrogenous extractives and lactose, 0.99; 
ash, 2.35; sodium chloride, 2.15. 

Lard. — Lard is the rendered fat of the hog. The fat is ex- 
tracted by means of heat which liquefies it and gradually frees 
it from the connective tissues. Lards are designated accord- 
ing to the portion of the animal from which they are pre- 
pared and the mode of rendering. "Neutral" and "leaf" 
lard are obtained from the fat surrounding the kidneys. 
The preparation of the former has already been indicated 
(p. 234). "Leaf lard" is obtained by heating the leaf fat 
or the residue from neutral lard to a higher temperature 
with steam. Kettle-rendered lard is made from leaf and 
back fat by heating in open jacketed kettles. Steam lard 
is made from the remaining portions of the hog not used for 
direct consumption by the direct application of steam. 

Various substitues for lard are prepared and sold under 
trade names. They are ordinarily mixtures of cotton seed 
oil and beef fat or specially treated cotton seed oil. 

VEGETABLE OILS 

Cotton Seed Oil. — Cotton seed oil is used extensively as 
a substitute for olive oil or in the preparation of substitutes 
for animal fats. In the preparation of cotton seed oil the 
cotton seeds are cleaned and ground, the meal heated under 
pressure to 210 to 215 F. and the oil expressed with hy- 
draulic presses while still warm and the crude oil refined. 
The best grades of cotton seed oil are practically free from 
any characteristic flavor and are suitable substitutes for 
olive oil. As with the butter substitute, oleomargarine, the 
real objection to its use is the economic one, that it is often 
sold as olive oil. However, it lacks the characteristic nat- 
ural flavor of olive oil. 

By a process of chilling and pressing the higher melting- 
point fats of cotton seed oil are partially separated from the 
more liquid ones. The former are used as substitutes for 
lard while the latter becomes a satisfactory oil for cold cli- 
mates. 



236 FAT-RICH FOODS 

Cotton seed oil is used extensively in the preparation of 
lard substitutes in which the fatty acids of the liquid unsat- 
urated fats are transformed, reduced, into their correspond- 
ing saturated compounds which are solid at the ordinary 
temperatures. These transformations ^ are brought about 
by heating with hydrogen in the presence of finely divided 
nickel. The nickel is added as a catalyst to hasten the re- 
action between hydrogen and the fatty acid. Small quantities 
of nickel remain in the final product and there is a possibility 
that they may be detrimental to health. This point has not 
as yet been determined. Such prepared products are as 
well utilized as lard and other fats and might well be substi- 
tuted for them when cheaper were it not for the nickel pres- 
ent. 

Olive Oil. — Olive oil is prepared by pressing the flesh of 
the ripe olive. The selection of the olive and the mode of 
preparation determine in general the grade of oil. The 
highest grade of oil, virgin oil, is from selected hand-picked 
olives. The product is obtained by slight pressure of cold 
olives. Subsequent pressure of the mass, first cold and then 
later heated with water, gives the various more or less in- 
ferior grades of oil. In some processes the olives are mac- 
erated and crushed before being subjected to pressure. The 
various oils obtained are subjected to a refining process in 
which foreign particles are removed by filtration and by 
gravity in settling tanks. Of the fatty acids present in fats 
of olive oil palmitic and oleic are the most important : there 
is little, if any, stearic acid. Other fatty acids are present 
but only in small quantities. Practically all of these fatty 
acids occur as neutral fat or glycerides; the small percen- 
tage which exists as free fatty acids varies with the ripe- 
ness of the fruit and the mode of preparation; most of the 
high grades of oil contain less than 3 per cent. Olive oil is 
eaten principally in salads; it is used to some extent in cook- 
ing. Other vegetable oils are used for food, such as peanut 
oil, sesame oil, cocoanut oil, etc. Vegetable oils have been 
found to be fully as digestible as animal fats. 

Corn Oil. — Corn oil is a by-product of the starch and glu- 
cose industry. It is obtained from the germ of the corn seed. 
The oil is golden yellow in color and has a pleasant taste and 
odor. It is satisfactory as a salad oil. 

GOD-LIVER OIL 

Cod-liver oil is prepared by means of pressure from the 
raw fresh livers of codfish. It has been used extensively 
because it is apparently assimilated under conditions in which 



COD-LIVER OIL 237 

other fat foods are not effective. It contains a number of 
low melting-point saturated fats in addition to olein, which 
is present to the extent of approximately 70 per cent., chol- 
esterol, a small amount of iodine, and a number of basic 
substances are also present. The presence in cod-liver oil 
of specific substances necessary for growth and maintenance, 
such as are found in butter and egg yolk, may be one of the 
reasons for its successful use in therapeutics. Cod-liver oil 
is sometimes adulterated by the admixture of other fish oils 
which results in an inferior product. Preparations are also 
sold which purport to have all of the therapeutic properties 
of cod-liver oil without the peculiar oily taste which is repug- 
nant to some persons. Those preparations from which the 
fat has been entirely or largely removed are practically use- 
less as substitutes for cod-liver oil since the therapeutic 
value rests as much in the readily assimilable oils as in any 
other factor. 



CHAPTER XV. 

FOODS VALUABLE FOR THEIR SALTS, VITA- 
MINES, WATER, AND BULK. 

In addition to those foods which furnish primarily pro- 
tein, carbohydrate, or fat is a group of foods which, while 
supplying these food-stuffs to a certain extent, are not suffi- 
ciently rich in them to be valuable sources of such material. 
They form, however, an important part of the diet because 
they are valuable sources of inorganic salts (particularly 
the salts of organic acids), of water, and of certain acces- 
sory food-stuffs essential for a satisfactory diet. They are 
comparatively indigestible. It is the indigestible residue 
which serves to give bulk to the intestinal contents and thus 
promotes peristalsis. Some of these foods contain a certain 
amount of soluble material which in itself stimulates peris- 
talsis — laxatives. These water-rich, indigestible foods are 
then a means of adding salts, accessory substances and bulk 
to the diet without markedly increasing the energy or pro- 
tein portion of the regimen. In addition to these purely 
material advantages they are in most cases appetizing and 
are in this way valuable as aids to digestion. To this class 
of foods belong the succulent plant foods — the vegetables 
and fruits. A clear-cut classification is difficult in a few 
cases. To classify dried legumes as protein foods, and 
fresh and . canned varieties of the same food as valuable 
chiefly for their salts and their value as appetizers may 
appear illogical. A consideration of their usual place in 
the diet, however, makes this the most desirable classifica- 
tion. Our discussion will confine itself, therefore, unless 
otherwise stated, to the succulent fruits and vegetables. 

Fruits and vegetables are composed largely of water; cellu- 
lose, the chief structural material; starches; sugars; organic 
acids; gums; mineral matter; protein, and a small amount 
of fat. So far as nutritive value is concerned, the quantities 
of the food-stuffs present are so small as to be practically 
negligible. The small amount of protein is poorly absorbed; 
carbohydrate, exclusive of cellulose, and fat are almost com- 
pletely digested, but the small quantity ingested is very 
seldom of practical importance. This is particularly true 
of the fat. 



COMPOSITION OF TYPICAL VEGETABLES 239 

The indigestibility of fruits and vegetables as a whole is 
due to the cellulose content. Cooking will increase the 
digestibility of this carbohydrate to a certain extent, parti- 
cularly in the case of raw fruit and the starchy vegetables 
for it softens the cellulose structures and ruptures the starch 
grains. The accompanying table gives the composition of 
some of the more important fruits and vegetables. 

Chemical Composition of Typical Fruits (per cent.), 
fresh. 







10 






"3 5 




. 


M .A 








c 




«5 


c 


- 


p- CO 

.5 OJ 


Fruits. 


u 

a 


3 a 


a 


x: u 
u 

.a 5 


.Q O. 

-a w 


CJ 

<v 
a 


*c5 cu 

> a 

« CO 


■50 

CO 

eg 




a 


a 


a 


3^ 


3 o 




cucu 


CO M 




£ 


£ 


fe 


U 


O 


< 


ta 





Apples 


. 84.6 


0.4 


0-5 


14.2 


1.2 


0-3 


285 


159 


Bananas . 


• 75 


3 


i-3 


0.6 


22.0 


I..O 


0.8 


447 


IOI 


Blackberries . 


. 86 


3 


1-3 


1 .0 


IO.9 


2-5 


0-5 


262 


173 


Cherries . 


. 80 


9 


1 .0 


0.8 


16.7 


0.2 


0.6 


354 


128 


Grapes 


• 77 


4 


i-3 


1.6 


19.2 


4-3 


0-5 


437 


IO4 


Huckleberries 


. 81 


9 


0.6 


0.6 


16.6 




0.3 


336 




Lemons 


. 89 


3 


1 .0 


0.7 


8-5 


1 . 1 


0-5 


201 


226 


Muskmelons . 


• 89 


5 


0.6 




9-3 


2 . 1 


0.6 


180 


252 


Oranges . 


. 86 


9 


0.8 


0.2 


11. 6 




05 


233 


195 


Peaches . 


• 89 


4 


0.7 


0. 1 


9-4 


3*6 


0.4 


188 


242 


Strawberries . 


. 90 


4 


1 .0 


0.6 


7-4 


i-4 


0.6 


177 


256 








DRIED. 












Apples 


. 28.1 


1.6 


2.2 


66.1 




2.0 


1318 


34 


Dates . 


• 15-4 


2. 1 


2.8 


78.4 




i-3 


1575 


29 


Figs . . . 


. 18.8 


4-3 


0.3 


74.2 




2.4 


1437 




Prunes 


• 22.3 


2. 1 




73-3 




2-3 


1368 


33 


Raisins 


14.6 


2.6 


3-3 


76.1 




34 


1562 


29 


Chemica 


l Composition of 


Typical 


Vegetables 


(per cent.). 








-5 






i« 




J5 . 






V 


CN 

\0 


j 


<u 


S§ 


_J 


"3 "2 










c 


ri . 


u t- 




- 


•u'C 


Vegetables. 


u 

V 


5« 


V 


u 

v 

O. 


>> a; 


5 a; 
ii'cu 




V 

a 


> a 


■53° 

CO 

p 

5 




rt 
£ 


a 


"3 


CO 


3 
»-l 


CO 


CL> CD 
3'"* 


cs „ 




Oh 


h 


O 


U 


< 


fe 





Asparagus 


• 94-0 


1.8 


0.2 


3-3 


0.8 


0.7 


101 


450 


Beans, fresh: 


















Lima 


• 68.5 


7-1 


0.7 


22.0 


i-7 


i-7 


557 


82 


String . 


• 89 


2 


2-3 


0-3 


7-4 




0.8 


189 


241 


Cabbage . 


• 91 


5 


1.6 


0-3 


5-6 


1 . 1 


1 .0 


143 


317 


Carrots 


. 88 


2 


1 . 1 


0.4 


9-3 


1 . 1 


1 .0 


205 


221 


Celery 


• 94 


5 


1 . 1 


0. 1 


33 




1 .0 


84 


540 


Lettuce . 


• 94 


7 


1 .2 


0-3 


2.9 


0.7 


0.9 


87 


524 


Potatoes: 




















White . . 


• 78 


3 


2.2 


0. 1 


18.4 


0.4 


1.0 


378 


120 


Sweet . 


. 69 





1.8 


0.7 


27.4 


1-3 


1 . 1 


558 


8l 


Pumpkins 


• 93 


1 


1.0 


0. 1 


5-2 


1.2 


0.6 


117 


389 


Spinach . 


. 92 


3 


2. 1 


0-3 


3-2 


0.9 


2. 1 


109 


418 


Tomatoes 


. 94 


3 


0.9 


0.4 


3-9 


0.6 


0.5 


104 


439 



240 FOODS VALUABLE FOR SALTS, WATER, ETC. 



Fresh vegetables and fruits have long been known for their 
anti-scorbutic properties. These have been ascribed to the 
predominance of the basic elements in the ash. While this 
may be a factor, recent work has shown the presence of the 
accessory food-stuffs, vitamines, which may be of much 
more importance. 

The constituents of vegetables and fruits which make 
them so desirable as foods are the salts and in fruits, the 
acids or acid salts, soluble sugars, and the essential oils, 
esters and ethers which give the pleasant taste. Cellulose 
is important for its laxative effect. The pleasing appearance 
of fresh and cooked vegetables and fruits has some esthetic 
value. Most fruits and many vegetables are palatable 
even in the raw state, in which form it is the crispness of the 
pulp or leaf which is particularly attractive. The delicate 
coloring matter which these foods contain is not only at- 
tractive to the eye but serves to stimulate the appetite. 
When cooked with sugar, as preserves or jellies, these color- 
ing matters and flavors are the means of increasing the appe- 
tite not only for the conserve itself but for insipid foods, 
chiefly carbohydrates, to which they are added. In this 
way they are valuable in the diet of the sick room. 

Vegetable foods are comparatively tasteless. To make 
them palatable it is necessary to add fats, usually in the 
form of oil or butter, and condiments, particularly acids, 
e. g., vinegar. The addition of salt to vegetables is also 
necessary. 

The importance of vegetables and fruits as sources of 
salts is indicated by the following table which gives the per- 
centage of individual ash constituents of typical vegetables 
and fruits: 

Composition of the Ash of Typical Fruits (per cent.). 1 









FRESH. 










Fruits. 


CaO. 


MgO. K 


,0. 


Na 2 0. P,0 5 . 


CI. 


s. 


Fe. 


Apples . 


.014 


.014 


15 


.02 


03 


.OO4 


.005 


.0003 


Bananas 


.01 


.04 


50 


.02 


055 


.20 


.013 


.0006 


Blackberries 


.08 


•035 


20 




08 




.01 




Cherries 


•03 


.027 


26 


•03 


07 


.01 


.01 


.0005 


Grapes . 


.024 


.014 


25 


•03 


12 


.CI 


.024 


.OOI3 


Huckleberries 


•035 


.025 






07 


.02 


.013 


.0011 


Lemons 


•05 


.01 


21 


.01 


02 


.01 


.012 


.0006 


Muskmelons 


.024 


.02 


283 


.082 


035 


.041 


.014 


.0003 


Oranges 


.06 


.02 


22 


.01 


05 


.01 


.013 


.0003 


Peaches 


.01 


.02 


25 


.02 


047 


.01 


.01 


.0003 


Strawberries 


■05 


•03 


18 


.07 


O64 


.01 




.0009 








DRIED. 










Dates . 


. 10 


•13 






12 


■ 32 


.066 


.003 


Figs . . 


.299 


• 145 I 


48 


.064 


332 


.056 


.056 


.0032 


Prunes . 


.06 


.08 I 


2 


. I 


25 


.01 


• 03 


.0029 


Raisins 


.08 


•15 I 


O 


• 19 


29 


.07 


.06 


.005 



Sherman: Food Products, 19 14, p. 347. 



COMPOSITION OF TYPICAL VEGETABLES 241 



Composition of the Ash of Typical Vegetables (per cent.). 



Vegetables. 
Asparagus 
Beans: 

Lima 

String 
Cabbage 
Carrots 
Celery . 
Lettuce 
Potatoes: 

White 

Sweet 
Pumpkins 
Spinach 
Tomatoes 



CaO. 
.04 

04 

075 

068 

077 

10 

05 

016 
025 

03 
09 
02 



MgO. 
.02 



II 

043 
026 

034 

04 

01 

O36 
02 

015 

08 

017 



K.,0. 
.20 

7 

28 

45 
35 
37 
42 

53 
47 
08 

94 
35 



Na.,0. 
.OI 

. 12 
■03 
•05 
•13 
. II 
.04 

.025 

.06 

.08 

.20 

.01 



D >o 3 . 


CI. 


.09 


04 


.27 


009 


. 12 


018 


.09 


03 


. IO 


036 


. IO 


17 


.09 


06 


■14 


03 


.09 


12 


. II 


01 


■13 


02 


•0.59 


03 



S. 


Fe. 


04 


.OOI 


06 


.0025 


04 


.OOI6 


07 


.OOII 


022 


.0008 


02.5 


. 0005 


014 


.OOI 


03 


.0013 


02 


.OOO5 


02 




041 


.OO32 


02 


.OOO4 



Green vegetables and fruits are an important source of 
iron. Investigations have shown that combined iron, such 
as occurs in nature is in a readily assimilable form, probably 
in the most desirable state. The iron of meat is chiefly in 
the form of hemoglobin, which is comparatively indigestible. 
The iron compounds of vegetables and fruits are, however, 
quite readily digested and absorbed. It is the availability 
of the iron which makes plant foods desirable in the diet for 
the iron they contain. 

The tables indicate only the relative amounts of the 
various elements, or their oxides, present in fruits and vege- 
tables. If we consider them with regard to the form in 
which these elements exist we find the basic elements com- 
bined with both inorganic and organic radicles. The or- 
ganic acids exist in many cases as the acid salts, chiefly the 
acid potassium salts. As the organic acids occur in the fruit 
or vegetable they exhibit in some cases a considerable degree 
of acidity, as is the case of lemons or apples. After absorp- 
tion in the body the organic acid is oxidized and the base, 
associated with the acid, combines with carbonic acid to 
form the carbonate which functions as a potential base. An 
examination of the ash of fruits and vegetables shows it to 
contain an excess of base over the acid-forming elements. 
In our discussion of inorganic salts it was noted that animal 
food is, with the exception of milk, potentially acid-yielding. 
Vegetables are then important in the dietary, for their 
ability to neutralize the acids produced in metabolism. In 
the case of fruits and vegetables it is the small amount of 
nutritive material associated with the salts which makes it 
possible to balance the diet with regard to its acid and alkali- 
forming properties, so as to aid in the maintenance of the 
neutrality of the blood. For the same reason, vegetables 
are important when it is desired to reduce the potential 
16 



242 FOODS VALUABLE FOR SALTS, WATER, ETC. 

acidity of the blood and urine. An excess of base-forming 
elements is not as objectionable as an excess of acid-forming 
elements because of the ever-present excess of carbon diox- 
ide to form bicarbonate with the base. The natural ten- 
dency to ingest plant food with meat in a mixed diet has had, 
therefore, a scientific foundation. The greater solubility of 
uric acid in an alkaline urine, resulting from the ingestion of 
an excess of basic material, than in a neutral or acid urine is 
also an advantage. 

The sugars of fruits and vegetables are chiefly sucrose 
(cane-sugar), dextrose, and levulose. Some fruits, such as 
the grape, often contain a high proportion of sugar. 

The more important plant acids are citric (lemon), malic 
(apple), tartaric (grape), and in some oxalic acid. The acids 
occur in varying proportions in the different fruits and vege- 
tables. The fruits designated in parentheses above are re- 
presentative of the class of fruit in which the particular acid 
predominates; other acids are also present. The relative 
proportion of starch, sugar and acid in fruits varies during 
the process of ripening. The following table gives the vari- 
ation in the composition of an apple at various stages of its 
growth. 

Composition of Baldwin Apple at Different Periods in Its Growth, 1 

Per cent. 

















Free 










Invert 




Total 




malic 




Condition. 


Water. 


Solids. 


sugar. 


Sucose. 


sugar. 


Starch. 


acid. 


Ash. 


Very green 


• 81.5 


18.5 


6.4 


1.6 


8.0 


4-1 


I .2 


O.27 


Green . 


■ 79-8 


20.2 


6-5 


4-1 


IO.5 


3-7 






Ripe . 


. 80.4 


19.6 


7-7 


6.8 


14-5 


0. 17 


O.65 


O.27 


Overripe . 


• 80.3 


19.7 


8.8 


5-3 


14. I 




O.48 


0.28 



Green fruit, in general, contains considerable starch. As 
the fruit ripens there is a gradual reduction in the quantities 
of the starch and acids and an increase of sugar. Pectin, 
the carbohydrate which forms the basis of jellies, gradually 
decreases as the fruit ripens. 

Cooking of Vegetables and Fruits. — Vegetables and fruits 
are cooked to soften the cellulose structure, rupture the 
starch grains, improve the texture and flavor, and thereby 
increase digestibility and palatability. Many fruits and 
vegetables which are also eaten in the raw form are cooked 
to add variety to the diet and for purposes of preservation. 
Heat converts the water in the cells into steam, the expan- 
sion of which ruptures the cells, freeing the enclosed starch; 
an exaggerated example of the expansive action of steam is 
seen in the popping of corn, in which expansion takes place 

Browne: Penn. Dept. Agr., Bull. 58. 



COOKING OF VEGETABLES AND FRUITS 243 



suddenly throughout the whole mass of starch cells when 
internal pressure is sufficient to rupture the tough outer 
layer of the kernel. During the process of cooking hydro- 
lytic changes occur: the starch and cellulose are partially 
hydrated, take up water, and are transformed into simpler 
products — glucose and sugars; protein is coagulated; the 
mineral salts are only slightly affected. 

Since inorganic salts are, from a dietetic point of view, 
one of the important food factors in fruit and vegetables, it 
is desirable then, to conserve them as much as possible. In 
boiling, the method usually employed for cooking vegetables, 
a large proportion of the salts and also protein may be lost; 
by direct removal before cooking, as in peeling; by extrac- 
tion in the water used in washing and soaking, or discarded 
with the water poured off at the end of the cooking process. 
Methods which will avoid these losses should be used. Bak- 
ing or steaming, with the least removal of outer coverings, 
is the most desirable. Some vegetables, such as spinach 
and chard, which are cooked by steaming in the water con- 
tained in them, are found to lose a large proportion of their 
salts when the liquor is poured off before they are served. 



Losses in Cooking Vegetables (Percentage of Fresh Edible 

Portion). 1 



Kind of vegetable. 



Solids. 



Ash. 



Spinach: 

Boiled 31 .59 

Steamed 0.18 

Cabbage: 

Boiled 32.86 

Steamed 2.54 

Carrots: 

Cut up and boiled . . 10.05 

Boiled whole 6.28 



P 2 O b . 

52.33 
5 23 

33-93 
1.79 

22.88 
17.97 



CaO. 



6.89? 
8.69 


60. 

7- 


7.66 
931 


26. 
4- 


0.88 
8-77 


19. 
19. 



MgO. 



Fruits and vegetables may be kept at ordinary tempera- 
tures for a considerable length of time before they begin to 
decay, wilt, or dry up. With proper refrigeration many of 
them can be kept for a comparatively long time. Such a 
method of preservation is becoming more prevalent, and 
some vegetables and fruits may be had throughout the year. 
Apples in particular are commonly preserved in cold stor- 
age. 

The process of canning fruit and vegetables has long been 
used by the housewife to preserve them for use when out of 
season. Canned foods can now be purchased in the stores 
in great variety, tomatoes, corn, and peas being supplied in 
the greatest quantity. Since canned fruits and vegetables 

1 Berry: Jour. Home Economics, 1912, iv. 



244 FOODS VALUABLE FOR SALTS, WATER, ETC. 

retain most of the properties of the freshly cooked food they 
are excellent sources of this type of food in the winter when 
green vegetables are generally "out of season." In canning 
vegetables and, to a certain extent fruit, are heated only 
enough to sterilize them. This is done after the can is sealed. 
Sugar is often added to fruit to aid in their preservation and 
increase the flavor. The juice of fruits is also sterilized and 
kept for use as beverages or mixed with sugar and made into 
jellies. It is the pectin of fruit which gelatinizes and forms 
the basis of jellies. 

FOOD ADJUNCTS. 

Food which is entirely satisfactory, in its quantitative 
composition, with regard to proteins, fat, carbohydrate, 
salts, and even the accessory substances or vitamines, may 
be in such a form that it is not relished; we have no desire 
to eat it. This distaste may be due to the appearance or 
taste of the particular food, or to a lack of interest in food 
in general. Such conditions are not confined to man alone. 
These factors do not affect the ultimate absorption of food 
so much as is sometimes thought, for food-stuffs which are 
ingested with much effort have been found to be just as 
thoroughly digested as those which are appetizing. The 
extent of variation in the diet is a matter largely of personal 
taste. Some people relish the same diet day after day, 
while others require frequent changes. Animals fed artifi- 
cial diets of similar composition from day to day often refuse 
to eat. If to the same diet small amounts of flavoring sub- 
stances, having no nutritive value, be added and the flavor 
changed from time to time, it will be eaten readily during 
long periods of time. There are also experiments on the 
flow of gastric juice which show that when there is desire for 
food, the mere sight of food results in a flow of highly acid 
and strongly active gastric juice which starts the process of 
gastric digestion, the products of which are capable of caus- 
ing a continued secretion. Certain food constituents, such 
as the extractives of meat and some condiments, are capable 
of stimulating such a flow of gastric juice, and this in turn 
affects the secretion of the other digestive juices. The 
garnishing of food when served likewise has through the 
increased attractiveness of the dish a beneficial effect upon 
the digestion of food. There is a fundamental reason, 
therefore, for the use of condiments and for different methods 
of preparing food. 

Spices. — Spices are used almost exclusively for their flavor. 
Such spices as allspice, cloves, cinnamon, ginger, caraway, 



BEVERAGES 245 

etc., are used chiefly in cooking. The peppers (black and 
white), paprika, mustard, and horse-radish are often added 
to food after it has been prepared. 

Flavoring Extracts. — Many alcoholic extracts of various 
plants of which vanilla, lemon, orange, peppermint, spear- 
mint, and wintergreen are the most common, are used to add 
an agreeable flavor or taste to foods. 

Meat Extracts. — Meat extracts are to be classed with the 
food adjuncts (see p. 183). 

Vinegar. — Vinegar is the product of the alcoholic and 
acetic acid fermentation of fruit juices; its distinguishing 
constituent is acetic acid. It may also be prepared from the 
products of alcoholic fermentation of grain or is compounded 
from acetic acid and substances to give a flavor and color 
which will simulate the natural vinegars. Vinegar is used 
with more or less insipid foods to intensify the flavor, and to 
soften food somewhat; for colloidal material tends to swell 
in acid solutions. 

Sugar and Salt (Sodium Chloride). — Sugar and salt may 
both be classified differently but may, for convenience, be 
included here as condiments, for they are used to add flavor 
and stimulate the appetite. 

Sugar Substitutes. — Saccharine, dulcin, granatose and 
saxin, benzene derivatives, are sometimes used in place of 
sugar to sweeten food. These products are used particu- 
larly to sweeten the food of diabetics and of the obese to 
increase its palatability without increasing the carbohydrate 
content. When taken in sufficient quantity these substi- 
tutes for sugar are harmful. It is the contention of manu- 
facturers that small quantities are not deleterious to the 
health. While this may be true during short periods of 
time, it is doubtful whether their continued ingestion may 
not cause serious disturbances in the body. Their use in 
diabetes is defensible on the basis that the harmful effects 
are overweighed by the possibility of reducing the carbohy- 
drate content of the food. 

BEVERAGES. 

Many foods are ingested in a liquid or semiliquid form. 
There are, however, liquids which possessing a certain amount 
of food value, are taken for their stimulating effects upon 
the nervous and digestive systems. The pleasurable condi- 
tions under which they are ordinarily ingested should not be 
neglected in considering the effect of these beverages. 

Those beverages most commonly taken with food and most 
properly considered a part of the diet are tea, coffee, cocoa, 



246 FOODS VALUABLE FOR SALTS, WATER, ETC. 

chocolate, and the malted and spirituous (and carbonated) 
liquors. 

Tea.- — Tea is prepared from the leaves and leaf buds of 
various varieties of hardy shrubs, Thea. Two general types 
of tea are used, green and black. This classification refers 
particularly to the general method of preparation. Green 
tea is prepared by steaming the withered leaves and then 
drying them in the sun or artificially, thus retaining the 
green color. Black tea has undergone a fermentation (or 
oxidation) process which darkens the color of the leaves and 
reduces the quantity of tannin. Numerous varieties of 
both kinds of tea may result from the selection of leaves 
from different parts of the shrub or twig or from the country 
or locality from which they are obtained. 

The active constituent of tea is theine or caffein, but cer- 
tain volatile oils and tannin contribute to the aroma and 
taste of the prepared beverage. In the preparation of the 
beverage it is the relative proportion of these three con- 
stituents to which most attention is given. The end com- 
monly believed to be desirable is the extraction of the maxi- 
mum amount of caffein and volatile oils, with the minimum 
quantity of tannin. 

From a study of the nature of the products extracted from 
tea leaves the Lancet has come to the conclusion that it is 
the relative proportions of caffein and tannin extracted which 
determine the quality of tea. They show that when caffein 
and tannin are present in the proportion of one part of caffein 
to three parts of tannin they may be precipitated completely 
by acidification in the form of caffein tannate. Caffein tan- 
nate has neither the astringent taste of tannin nor the bitter 
taste of caffein, and it is precipitated by acids. It has been 
suggested that the caffein of tea, unlike the caffein complex 
of coffee, is precipitated in the stomach and is not absorbed 
until it reaches the alkaline intestine. A comparison of the 
valuation of tea by tea-tasters and the proportion of caffein 
to tannin in the tea shows that the infusion of those teas 
classed as "good" contain these two substances in the pro- 
portion in which they exist in caffein tannate, and that in- 
ferior teas yield an excess either of caffein or of tannin in the 
infusion, usually the former. 

The following table shows the extractives from teas of 
three different types and the relative proportion of caffein 
and tannin contained. It will be seen that the high-priced 
teas contain a greater proportion of tannin and caffein 
(caffein tannate). 







BEVERAGES 






247 


Tea 


Infusions (5 Grams of 


Tea to 


400 C.C. 


Boiling 


Water). 




Tea. 


Caffein 
tannate. 
Deter- 
mined. 


Tannin Caffein 
com- com- 
bined bined 
with with 

caffein. tannin. 


Total 
tannin. 


Total 

caffein. 


Caffein 
not 
com- 
bined. 


Tannin 
not 
com- 
bined. 


Price, 
cents . 


ndia 


8-54 


6.4I 2.I3 


6.80 


2.56 


0.43 


0-39 


15 


Ceylon . 


I3-36 
8.88 


I0.02 3.34 
6.66 2.22 


IO.92 
6.3O 


4-32 
2.8o 


O.98 
O.58 


O.9O 


46 
17 




12.00 


9 . 00 3 . 00 


8.4O 


3.60 


O.60 




33 


China 


536 
6.48 


402 1.34 
4.86 1.62 


3.02 
4.60 


I.92 
2.80 


O.58 
I. 18 




13 

35 



The chemical composition of the water used in making tea 
may affect the composition of the infusion, for, should the 
water be rich in calcium, the calcium will tend to precipitate 
the tannin and leave an excess of caffein. The period of 
extraction affects the composition of the infusion ; continued 
extraction of good tea results for a time in a proportionate 
increase in both caffein and tannin so that the balance is but 
little disturbed; inferior teas, on the other hand, yield an 
excess of either caffein or tannin. Prolonged boiling of tea 
tends to extract a greater proportion of tannin. The Lancet 
believes that caffein and not tannin is the injurious consti- 
tuent of tea, for tannin is rarely in excess of the ratio in which 
it exists in caffein tannate. Studies of the quantity of caf- 
fein and tannin present in tea steeped for varying lengths of 
time have shown that practically all of the caffein is ex- 
tracted in the first three to five minutes. A longer period 
of extraction results in an increased proportion of tannic 
acid in the infusion. For those, then, who desire to obtain 
the maximum aroma and exhilarating effect of the caffein 
without the bitter, stringent tannin, tea should be extracted 
for a short period. 

The total quantity of caffein and tannin present in the 
average cup of tea after an infusion of five minutes varies 
with the kind of tea — it has been found to be roughly 1 
grain (0.07 gram) of caffein and three or four times as much 
tannin. The effects of tea are discussed with those of coffee 
on p.* 250. 

Coffee. — The beverage coffee is prepared from the roasted 
bean, of the Caffea arabacia. The coffee berry contains a 
bean composed of two elongate, hemispherical halves en- 
closed in a thin membranous sheath, which is surrounded 
by an outer layer of pulp. The berries are separated and 
roasted to preserve them, to render them brittle and readily 
ground, and to develop certain flavors and aroma. In the 
roasting process a large proportion of the sugar is caramelized 
and there are losses of water and to a certain extent of caf- 
fein. Caffeol is the name given to a mixture of substances 



248 FOODS VALUABLE FOR SALTS, WATER, ETC. 

present in the roasted product which gives to coffee its 
characteristic flavor and aroma. The alkaloid of coffee is, 
as in tea, largely caffein. 

The caffein of coffee is combined in a different manner 
from that of tea; it is almost entirely extracted by cold 
water while that of tea is not. It appears to be combined 
with an acid designated as caffetannic acid related to tannin 
but exhibiting properties different from those of the tannic 
acid of tea. The caffein of coffee is soluble in both an acid 
and an alkaline medium, while that of tea is precipitated 
by acids. This fact may account for the greater stimula- 
tory effect of coffee than of tea, for the caffein being in solu- 
tion may be absorbed by the stomach, while that of tea must 
pass to the intestines for solution and absorption. 

The several kinds of coffee vary chiefly according to the 
country from which they are obtained. As with tea the 
advantage of the different kinds is to a considerable extent 
a matter of taste. 

The coffee bean contains roughly one-third the quantity 
of caffein present in dry tea. The greater quantity of coffee 
used gives approximately the same quantity of caffein in 
both prepared beverages. Coffee contains a greater amount 
of total extracted material. 

In the process of preparing coffee for its most pleasurable 
effects the caffein and the aroma are the two constituents 
which it is desirable to extract. It has been found that when 
2 ounces (60 grams) of coffee are used, a teacupful of coffee 
will contain approximately 1.7 grains (0.1 gram) of caffein, 
a value which is slightly higher than that of tea; the smaller 
quantity of infusion taken when cream or milk is used will 
make this value slightly lower. The quantity of caffein 
and caffetannic acid extracted in the preparation of coffee 
varies considerably with the mode of preparation. Cold 
water extracts approximately the same weight of mate- 
rial from coffee as does hot water, but hot water extracts 
oils which improve the odor and taste of the beverage. 

Four general methods of preparing the beverage coffee 
are used: boiling, steeping, percolation, and filtration. 

Boiled coffee is prepared by heating medium-ground coffee 
placed in cold water to the boiling-point and maintaining it 
at that temperature for five minutes. This method gives 
the greatest proportion of extract, and one which is rich in 
caffein and caffetannic acid. 

Steeped coffee is similar to boiled coffee except that the 
infusion is poured off soon after the boiling-point is reached. 
This method yields the lowest caffein content. 



BEVERAGES 249 

Percolation consists in passing warm water through finely 
ground coffee in a specially constructed coffee pot. The 
temperature of the water which is forced over the coffee 
seldom reaches the boiling-point. A low total extract high 
in caffetannic acid and caffein is obtained. 

Filtered coffee is made from finely pulverized coffee which 
has been placed in a muslin bag and over which vigorously 
boiling water is poured. The product is lower in total ex- 
tractives and contains less caffetannic acid than boiled coffee. 
If the water be poured through more than once a darker 
liquid is obtained which has a less agreeable flavor because 
of the additional tannin and other objectionable substances. 
This method of preparing coffee is in many ways the most 
satisfactory. 1 The cloth used should not be allowed to dry 
but should be kept in clear cold water. 

A comparison of the relative quantities of caffein and tan- 
nin extracted by the various methods is given below. 

Tannin and Caffein Extracted by Various Methods of Preparation 
(7 Tablespoonfuls (80 Grams) Coffee to 6 Cups (750 c.c.) Water). 

Tannin, Caffein, 

Method of preparation. grains. grains. 

Boiled ...*.... 2.44 2.5 

Steeped 2.40 J 0.5 medium ground 

1 ^ 1175 finely ground 

Percolated 2.21-2.90 2.75 

Filtered 0.2-0.25 2.50 

Specially prepared coffees are sold for the use of those 
who cannot take coffee because of its caffein content, usually 
with the implied statement that some or most of the harm- 
ful ingredients of coffee have been removed. After a com- 
parison of some of these with three types of pure coffee the 
following statement has been made: 2 

"'Kaffee Hag' is almost caffein-free but contains the 
normal amount of caffetannic acid. 'George Washington 
Coffee' (a soluble concentrated coffee) contains about four 
times as much caffein and caffetannic acid as normal coffee. 
'Cafe des Invalides' contains about 80 per cent, as much 
caffein as ordinary coffee, the decrease being due to its dilu- 
tion with other vegetable substances; its caffetannic acid is 
somewhat higher than in normal coffee. 'Richelieu Vacuum 
Coffee' contains practically the same amount of caffein and 
caffetannic acid as ordinary coffee." 

Certain coffee substitutes prepared from roasted grains are 
sold for the use of those who desire a beverage simulating 
coffee but who do not wish to ingest the alkaloid caffein. 

x Aborn: Tea and Coffee Trade Jour., 1913, xxv, 568. 

2 Food Products and Drugs, Report of Conn. Agr. Exp. Sta., 191 1, Pt. 5. 



250 FOODS VALUABLE FOR SALTS, WATER, ETC. 

These products accomplish this end more or less satisfac- 
torily although their action is chiefly that of a warm bever- 
age. 

The general effect of tea or coffee is to produce wakeful- 
ness and relief from fatigue, increased strength and rapidity 
of the heart beat and increased blood-pressure. In some 
people drowsiness rather than wakefulness is induced by 
coffee: this is usually followed by a period of wakefulness. 
These effects are to be ascribed chiefly to the caffein contained 
in them; caffein also has a diuretic effect. The feeling of 
well-being which accompanies the ingestion of coffee after 
a meal has been ascribed to the local action of the contained 
oils. 

The effect of coffee upon digestion is to increase the period 
of gastric digestion without affecting it quantitatively. 
Since the direct effect of water when taken with food is to 
delay evacuation of the stomach, the best results are ob- 
tained when water and other liquids are taken after food 
rather 'than when mixed with it. On the other hand, the 
ingestion of bread or cake with coffee is desirable, for it 
prolongs the feeling of satiety and delays diuresis. Coffee 
infusion has been found to tend to inhibit the coagulation 
of milk and to inhibit peptic activity outside the body while 
tea has a less retarding action on coagulation and appears 
to promote peptic activity. 

The harmful effects of tea and coffee are sometimes re- 
ferred to the tannin content because tannic acid precipi- 
tates protein, simple protein cleavage products, and diges- 
tive enzymes. The work performed for the Lancet tends to 
show for tea, at least, that in good teas the tannin is so com- 
bined with caffein that it will be precipitated out by the 
gastric juice and only become absorbable in the intestine 
in which the alkaline tannate would not have the precipi- 
tating power of tannic acid. They are therefore inclined 
to ascribe the harmful effect of tea to caffein. 

The slight laxative effect of hot drinks is probably to be 
ascribed chiefly to the hot water. 

Cocoa and Chocolate. — Cocoa and chocolate are prepared 
from the seed or bean of the tree Theobroma cacao. The 
beans are removed from the pod, fermented in boxes or in 
holes in the ground, and then dried in the sun until they 
assume the characteristic brown color of the beans shipped 
to the market. In the preparation of the products cocoa 
and chocolate the dried beans are cleaned, roasted, crushed, 
and finally ground, after which the ground mass is molded 
or specially treated according to the nature of the final pro- 



BEVERAGES 251 

duct — chocolate or a special variety of chocolate such as 
milk chocolate or cocoa. It is during the fermentation pro- 
cesses just after picking and the subsequent roasting pro- 
cesses that care must be taken if the product is to develop 
the most desirable flavor. 

Ground cocoa nibs, obtained by crushing the roasted 
beans, constitute the ordinary chocolate of commerce. 
Sugar, dried milk, flavoring extract (particularly vanilla), 
etc., are added to the ground mass in the preparation of 
sweet chocolate, milk chocolate, etc. 

In preparing cocoa a portion of the oil or fat is removed 
from the ground seeds. This fat is removed by pressure — 
usually when warmed slightly; the residue is the finely pul- 
verized cocoa of commerce. The expressed fatty material 
is cocoa butter, a semisolid fat used in the manufacture of 
chocolate and particularly in pharmaceutical preparations. 
Alkaline salts, sodium, potassium or ammonium carbonate, 
are often added to the ground cocoa ostensibly to increase 
the solubility of the product; such products are sometimes 
designated as "Dutch process" cocoa. The addition of 
alkali neutralizes any fatty acid present. Tests of these 
preparations in comparison with untreated preparations have 
failed to show any marked increase in solubility; such treat- 
ment would tend, however, to aid in the emulsification of 
the cocoa fat and thus produce an apparent increase in solu- 
bility. 

Specially prepared cocoas are sold which have been treated 
with alkali as indicated above or with the addition of sugar, 
starch, etc. 

Comparative Composition of Products of the Cocoa Bean. 1 





Cocoa nibs. 


Chocolate. 






Cocoa 


. 




Original 




Original 




Original 






material. 


Fat-free. 


material. 


Fat 


free. 


material. 


Fat-free 


Ash. . 


3-32 


6.66 


3-15 


6 


59 


5-49 


7-49 


Soluble ash 


1.16 


2-33 


1. 41 


2 


95 


2 


82 


3-85 


Sand 


0.02 


0.04 


O.06 





13 





24 


0.32 


Nitrogen 


2.38 


4-77 


2.26 


4 


73 


3 


33 


4-54 


Fat . . 


50.12 




52.19 






26 


69 




Fiber . 


2.64 


5 29 


2.86 


5 


98 


4 


48 


6. 11 


Starch . 


8.07 


16.18 


8. 11 


16 


75 


11 


14 


5.20 



Cocoa and chocolate differ, as indicated above, particu- 
larly in the quantity of fat present. Cocoa contains roughly 
one-half as much fat as chocolate. The fat is largely a mix- 
ture of the glycerol esters of palmitic, stearic, lauric and 
arachidic acids, melting-point 3S to 33 C. 

The active principle of cocoa and chocolate is theobro- 
mine, or trimethylxanthin, and is closely related chemically 

1 Winton: Conn. Agr. Exp. Sta. Report, 1902, p. 282, 



252 FOODS VALUABLE FOR SALTS, WATER, ETC. 

to the caffein of tea and coffee. There is roughly about as 
much theobromine in cocoa as there is caffein in tea or coffee, 
between i and 2 per cent., less in the specially prepared pro- 
ducts because of the dilution with other substances; a 
small amount of caffein is present. Tannin is also present; 
the reddish color of the finished product has been held to be 
an oxidation product of the tannin present in the raw bean. 

Cocoa and chocolate contain theobromine which does not 
have the stimulating power of caffein, and these drinks are 
therefore less objectionable from that point of view. Be- 
cause of the high fat content they tend to retard the passage 
of food from the stomach. While these beverages are pre- 
pared from substances with a high food value the prepared 
liquid is comparatively low in such value because of the 
relatively small quantity of material used; the added milk 
is often of more importance. 

Mineral Waters. — Water may be roughly divided for 
convenience into three classes: hard, soft and " mineral" 
water. The presence of considerable quantities of the salts 
of the alkaline earth metals, particularly calcium and mag- 
nesium, is the chief characteristic of a hard water. Water 
analysts recognize two degrees of hardness: temporary and 
permanent. The quantity of calcium and magnesium pres- 
ent in water as the bicarbonate which may be precipitated 
through the removal of carbon dioxide by boiling or by the 
addition of lime is an index of the temporary hardness of 
water. When combined with the chloride or sulphate 
radicle calcium and magnesium are not precipitated readily 
by heating and the water is said to be permanently hard. 1 

Soft waters are comparatively free from dissolved inor- 
ganic matter. Distilled water is an artifically prepared soft 
water and is free from inorganic salts; it may contain a 
certain amount of ammonia. Rain water, when properly 
collected is virtually free from inorganic salts. It often 
contains a certain amount of organic material, particularly 
when collected from the roof. 

The term " mineral water" is applied to those naturally 
occurring (and also artificially prepared) waters rich in par- 
ticular salts or gases as distinguished from the usual table 
water poor in such constituents and having no specific effect. 

^he temporary hardness of water may be removed by adding to it a saturated 
solution of calcium hydroxide," lime water. " In the presence of calcium hydrox- 
ide the calcium bicarbonate is changed into normal calcium carbonate which pre- 
cipitates, and in this way both the calcium of the water and the calcium of the 
added lime water are removed. The quantity of lime water to be added to any 
water must be determined by experiment or it may be approximated from pub- 
lished analyses of the water under consideration. 



BEVERAGES 253 

The name has developed particularly in conjunction with the 
therapeutic use of such water. The classification of mineral 
waters has not been standardized. Since they are ordinarily 
used for their medicinal effect it is perhaps best to classify 
them according to the nature of the substance contained, as 
lithium water (lithia) ; sulphurous water; sulphate water 
(aperient) ; iron water (chalybeate) ; radio-active water. To 
these should be added the alkaline waters, a type which may 
include one or more of the types of water just named. Many 
waters are rich in sodium chloride and are sometimes desig- 
nated as saline waters. Some waters are naturally charged 
with carbon dioxide while others are sold artificially charged. 
The classification indicated above recognizes only the most 
characteristic constituent of mineral water; it may contain 
one or all of the other constituents. 

Lithium waters, or lithia waters, are waters which have 
been advocated because of the supposed solvent effect of 
lithium upon uric acid in the body. Consideration of the 
ionic equilibrium in the body makes it appear very impro- 
bable that the ingested lithium salts could dissolve uric acid 
to any considerable extent. Since most lithia waters are 
comparatively poor in lithium, large amounts of water would 
need to be taken to produce even a slight effect. 

Sulphurous water contains hydrogen sulphide gas as the 
most characteristic constituent. The gas is liberated readily 
unless properly bottled; to obtain hydrogen sulphide, there- 
fore, the water should be taken at the spring. The curative 
power of such waters is probably due to other constituents 
than the gas itself. It may be in the sulphur, sometimes 
"used as a blood purifier. " Sulphurous waters are found at 
the Anderson Sulphur Springs in California, French Lick 
Springs, Richfield Springs, and Cold Sulphur Springs. 

Sulphate waters are rich in alkali and alkali earth sul- 
phates, such as sodium sulphate (Glauber's salt) and mag- 
nesium sulphate (Epsom salt) ; these two salts usually occur 
together. Such waters are laxative and purgative, the effi- 
ciency varies with the amount of magnesium and sodium 
present. Many of these waters are concentrated by evap- 
oration and are to be diluted or dissolved before using. Salts 
(sulphates) are sometimes added to the natural water to 
increase its concentration. Some American waters rich in 
sulphates are found at the Mendenhall Springs, Isham and 
Nuvida Springs in California; the Warm Springs, Hot 
Springs and Healing Springs in Virginia. Foreign waters 
such as Hunyadi Janos, Kissengen, Seidlitz and Friedrichs- 
hall are of this type. 



254 FOODS VALUABLE FOR SALTS, WATER, ETC. 

Iron waters usually contain other mineral constituents 
which may have as great an effect as the iron itself, such as 
carbonates, sulphates, lithium, and arsenic. Many waters 
used as table waters are rich in iron. The presence of the 
associated salts must be considered in prescribing iron waters ; 
a water containing bicarbonates is preferable as a tonic. 
The Berkely Springs, West Virginia, and the Round Spring 
at the Aurora Springs, Missouri, are examples of American 
iron-containing bicarbonate springs. Similar foreign waters 
are to be found at Spa, Belgium; St. Moritz, Switzerland; 
Schwalbach, Germany; Trubridge Wells and Flitwick Well, 
England. 

Radio-active Water. — The presence of traces of radium in 
certain waters has led to their use in therapeutics. It has 
been found that such waters lose their radio-activity with 
time. Springs which have been advocated for their healing 
properties because of the presence of various salts have been 
found to be, in addition, radio-active. Many waters, such 
as those at Hot Springs, Arkansas, the mineral springs of 
Yellowstone Park in America, and the foreign waters at 
Carlsbad, Gastein, Wiesbaden, Kissengen and Bath have 
been found to be radio-active. Radio-active water is arti- 
ficially prepared and sold or may be prepared with suitable 
apparatus. 

Alkaline waters include particularly those of the lithium, 
sulphate and iron types. They are valuable as a means of 
administering alkaline salts. The alkalinity of these waters 
is due to the presence of bicarbonates, primarily of sodium, 
potassium, or lithium and secondarily of magnesium and 
calcium. Many alkaline waters are effervescent. Vichy 
water is perhaps the most generally used alkaline water. 
Some American alkaline waters are: White Rock and Clys- 
mic (Wakeshau, Wisconsin) ; Vichy (Saratoga Springs, New 
York) ; Londonderry Spring (New Hampshire) ; Hot Springs 
(Arizona). Vichy (France), Carlsbad (Austria), and Fach- 
ingen (Germany) are alkaline European waters. 

An analysis of the various medical data with regard to the 
use of mineral water has brought out the following facts. 1 
(a) many patients are improved in health under mineral 
water treatment; (b) waters of widely different composition 
have been recommended for the same disease; (c) curative 
properties are ascribed to many waters whose mineral con- 
tent is the same as, or lower than, the city supplies used 

X R. B. Dole: The Production of Mineral Waters in 1911, U. S. Geol. Survey, 
advance chapters for Mineral Resources of United States, 19 12. This discus- 
sion of water is taken in part from this paper. 



BEVERAGES 255 

daily by many people without peculiar physiological effects; 
(d) treatment at resorts is often recommended for those 
afflicted with chronic organic diseases, many of which are 
obscure in nature or are caused by failure of nutrition. Such 
facts lead to the conclusion that the beneficial effects are to 
be ascribed more to the free use of water itself, augmented 
by dietetic treatment, exercise, and other hygienic restric- 
tions and possibly change of climate and freedom from busi- 
ness and household cares than to the contained mineral con- 
stituents. 

The demonstration of the value of various waters will 
depend upon the concentration of the dissolved constituents. 
The determination of the effects of a particular water is 
difficult to accomplish because of the difficulty in controll- 
ing the physiological factors associated with its ingestion. 
The specific action of salts may occur in three ways : as stimu- 
lants to (a) increase or (b) depress the activities of an organ 
or function or (c) as irritants which cause a change in form, 
growth, and nutrition, rather than of activity. The action 
of mineral waters is due to the contained ions rather than to 
the undissociated salt. The effect of any particular ion will 
depend upon its associated acidic or basic radicle and the 
presence of other ions in solution. When two ions occur 
together one ion may neutralize the effect of the other. Such 
an effect is apparently specific and not necessarily in the 
ratio of the combining power of the ions; thus, roughly, 
one part of calcium chloride will neutralize or antagonize 
the effect of one hundred parts of sodium chloride in its effect 
upon the permeability of membranes. This antagonistic 
action of ions may be the explanation of the tolerance of 
comparatively large quantities of some mineral waters. We 
know that a tolerance for water is acquired; the develop- 
ment of diarrhea in some persons upon moving from one 
locality to another may be looked upon as of this nature. 1 

The fact that an individual dose of a salt is not harmful 
does not mean that its continued ingestion may not be injuri- 
ous, for small repeated doses of a salt will in some cases in- 
duce symptoms which are more marked than from a single 
dose, such as in lead poisoning, or an abnormal tolerance 
may be acquired as in the case of arsenic. 

Analyses of water do not tell the manner in which the 
various ions are combined but only their proportionate dis- 
tribution. From such analytical data we say by inference 
that the ions exist in certain combinations. These com- 
binations are hypothetical, for the complex combinations of 

diarrhea may be due to infection from a water new to the individual. 



256 FOODS VALUABLE FOR SALTS, WATER, ETC. 

various salts and the effect of loss of dissolved gases, particu- 
larly carbon dioxide, alter the molecular and possibly ionic 
complexes actually present in the original water analyzed. 

The results of water analyses are usually expressed in 
parts per million. 

The following equivalents of certain methods of express- 
ing analytical results will aid in understanding the signifi- 
cance of this expression. 

Equivalent in parts 
per million. 

I part in ioo I part in 10,000 

1 part in 1000 1 part in 1,000 

1 gram in a liter 1 part in 1,000 

I milligram in a liter 1 part 

Grains per imperial gallon — 0.07 gives parts per million. 
Grains per U. S. gallon ~ 0.058 gives parts per million. 

Dole has suggested the use of the quantity of a specific 
salt in four kilograms of water (the water intake for a day) 
as the basis of differeniation between medicinal and common 
water with reference to the minimum dose of the individual 
constituent in the absence of other ions which have a phar- 
macological effect, ignoring as difficult of demonstration the 
effect of associated ions. 

The following table of the minimum dose of constituents 
common to mineral waters has been prepared by Dole: 

Average Equivalent 

minimum dose, concentration, 

Radicle. grams. mg. per kg. 

Arsenite (AsOs) / \o.2 

Arsenate (AsO) \ 0.0002 j Q3 

Fluoride (F) 0.002 0.5 

Barium (Ba) 0.003 °-7 

Hydroxide (OH) 0.013 3.0 

Aluminum (Al) 0.011 3-0 2 

Iron (Fe) . 0.024 6.0 

Lithium (Li) 0.075 I 5-° 

Ammonium (NH*) 0.078 20.0 

Manganese (Mn) .' 0.12 30.0 

Metaborate (BO) ) (3) Uo.o 

Pyroborate (B407) ( U • ■ • °° 35 ?30.o 

Iodide (I) . ■ 0.12 30.0 

Calcium (Ca) 0.2 50.0 

Magnesium (Mg) 0.2 50.0 

Orthophosphate (PCM) 0.23 50.0 

Carborate (CO) . . .0.281 70.0 

Sulphite (SO) 0.315 70.0 

Thiosulphate (S^O) 0.300 70.0 

Nitrate (NO) 0.5 100. o 

Bromide (Br) . . . . • 0.53 100. o 

Sulphate (SO*) 0.60 150.0 

In preparing the table care was taken that the concentra- 
tion expressed should represent a minimum below which 

1 Equivalent as arsenic (As); 2 in acid solution; 3 equivalent as boron (B). 



BEVERAGES 257 

therapeutic activity could not logically be attributed to the 
radicle in question. 

The significance of the last column may be illustrated as 
follows: If the average quantity 0.53 gram of bromine were 
in four kilograms of water the concentration of the radicle 
would be 132 milligrams per kilogram (reduced to 100 in 
the table), that is, a person who drank 4 kilograms of water 
containing 132 milligrams per million by weight of bromide 
might exhibit symptoms produced by bromides, if the water 
did not contain some other radicle which was antagonistic. 
530 kilograms, roughly quarts, of bromide water containing 
one part per million of bromine would have to be ingested to 
obtain a similar effect. 

Alcoholic Beverages. — Beverages containing alcohol are 
used chiefly for their psychological effects. They have, as a 
rule, a pleasant taste, often a fragrant odor, and are usually 
cooled, factors which make their consumption a pleasure. 
In sufficient quantities their use is accompanied by pleasur- 
able after-effects, a sense of exhiliration, relief from fatigue, 
and warmth, followed, however, in many cases by depression. 
The effect of moderate quantities, 30 to 40 c. c, of alcohol, 
is to quicken the heart beat without materially raising the 
blood-pressure; larger quantities produce a fall in blood- 
pressure except in certain abnormal conditions of the circu- 
latory system, a result which is due to a depressant action on 
the nervous centers and in part to a weakened heart. The 
general effect is that of a narcotic rather than of a stimulant. 
There is an increased rate of respiration, disturbed heat 
regulation, and secretion of saliva and gastric juice. While 
alcohol produces, for the time being, a feeling of well-being, 
and ability to work, these are more or less subjective effects. 
The true result appears to be a lowered capacity for work, 
particularly work requiring thought, and lessened endurance. 

A thorough and far-reaching study of the effect of alcohol 
upon the body processes is being undertaken by Benedict in 
the nutrition laboratory of the Carnegie Institution of Wash- 
ington. This series of investigations has only been started. 
The results of a psychological study indicate that the period 
of response in the simple reflex arcs in the lumbar cord, the 
patellar reflex, and the protective-lid reflex and to more com- 
plex cortical arcs, certain eye reactions to peripheral stimuli, 
speech reactions to visual word stimuli, and free associations 
were increased following the ingestion of doses of alcohol 
containing 30 c.c. and 45 c.c. of absolute alcohol; memory 
and free association were only slightly affected. 
17 



258 FOODS VALUABLE FOR SALTS, WATER, ETC. 

As a food, alcohol is of the type of the energy-yielding 
food-stuffs, fats and carbohydrates. It can be substituted 
for them at least to a limited extent and is capable of exert- 
ing a similar sparing effect upon protein. Its use must, 
however, be considered in connection with the fact that alco- 
hol has also a toxic effect foreign to fat and carbohydrate. It is 
not converted into sugar by the diabetic and may then be- 
come a source of energy. It is not, however, an antiketo- 
genic substance. The use of alcoholic beverages as food is of 
only secondary importance. Alcohol or even beverages 
fortified with sugar, such as some wines, are not economical 
sources of energy and there is no proof that alcohol itself is 
more efficient than carbohydrate in the body economy. 
The trend of the evidence is rather against such a possibility. 
Discussion of the use of alcohol as food has therefore little 
practical dietetic value; the food or fuel value of alcohol is 
a bone of contention between those advocating its use in 
general and their opponents. 

Studies of the food value of alcohol have shown that from 
90 to 98 per cent, of alcohol ingested in small quantities is 
oxidized; that the effect of the addition of the equivalent of 
500 calories in the form of alcohol, 72 grams, to a standard 
diet was practically identical with the addition of an equiva- 
lent amount of sugar, and that alcohol is not as efficient in 
sparing protein as carbohydrate or fat. Certain investiga- 
tions have demonstrated in short experiments that for small 
amounts of alcohol there is an increased protein metabolism. 
Experiments of longer duration have shown that there is an 
initial rise in the nitrogen excretion (loss of protein) but that 
in the course of a few days the metabolism returns to the 
normal, or there may be a retention of nitrogen. The utili- 
zation of foods is unaffected by the ingestion of small amounts 
of alcohol. These observations, which apply only to small 
quantities of alcohol, have demonstrated quite clearly that 
it may serve as a food. Large doses of alcohol exert a toxic 
effect, increase protein metabolism, and also the respiratory 
exchange; as the result of the restlessness of partially in- 
toxicated persons. With complete intoxication the energy 
exchange is decreased. 

The desirability of using alcohol as a food under all cir- 
cimstances is doubtful; the associated danger of excessive 
consumption should certainly bar it as a constituent of the 
diet. While it can replace in part fats and carbohydrates it 
does not serve as a reserve food in the sense that these foods 
do, for it is oxidized immediately. 



BEVERAGES 



259 



The therapeutic use of alcoholic beverages in medicine, 
such as in the treatment of fevers on the basis that it is a 
readily assimilable and oxidizable type of food in a condition 
in which food is more or less contraindicated, loses its import- 
ance somewhat in the light of our present knowledge of the 
effect of food in such cases. With regard to the combined 
stimulating and food value of such beverages and their 
effect upon the appetite, little of a definite nature can be said. 

Alcoholic beverages are products obtained as the result of 
the alcoholic fermentation of sugar or prepared from fer- 
mented products. They are of two types, fermented and 
distilled. Fermented liquors are the result of naturally 
occurring fermentations. Of these there are (a) the products 
of direct spontaneous fermentation of saccharine fruit juice 
such as wine and cider, and (b) beverages produced from 
starch-bearing grains in which alcoholic fermentation takes 
place after the conversion of starch into sugar, such as the 
malted and brewed liquors, beer, ale, etc. 

Distilled liquors, sometimes designated as " spirits, " such 
as whiskey, brandy and rum, etc., are obtained by the dis- 
tillation of naturally fermented products. 





Composition 


OF Alcoh 


OLIC 


Liquors. 














Alcohol 










Acidity 
















£ 

01 


















o 




V 




3 


















-a 


X 


£ 




O 




■d 

3 














c 
o 

-2 


M 


3 




to 




a 




4J 










'3 


O 
> 




M 
O 


05 


CO 

s 


■d 


1 


75 




(D 




a 


>> 








- 




"o 


o 


to 






U 


PQ 


m 


W 


2 


W 


O 


£ 


> 


H 


< 


cC 


Beer, lager . 


0.4 


4.3 


5.6 


4.2 


i 0.5 


110 


1 16 






0.06 


0.20 


0.06 


Porter .... 


3 i 


61 


7.7 


5.9 


08 


0.57 


2.8 






0.15 


0.37 


005 


Ale 


05 


5.7 


71 


4.4 


05 


0.49 


2.2 






0.12 


0.31 


0.07 


Malt extract. 1 


























U. S. P. . . . 








766 


3.1 


6540 


6.9 




002 


0.26 


120 


056 


Claret .... 




97 








024 




0.39 


0.17 


0.60 


0.21 




Sherry .... 




178 








3.00 




029 


0.16 


049 


050 




Port 




181 








2.54 




031 


009 


0.43 


0.23 




Champagne . 






13^7 


3.67 




192 








0.40 






Whiskey .... 




43^6 


51.2 


Oil 












336 






Brandy .... 




41.1 


48.5 


0.67 












3.75 






Gin 




40.2 


47.5 


0.05 












192 






Liqueur .... 




38.5 


52.0 


36.00 




32 '60 










041 




Cider: 


























Hard . . . . t 


rac 


e 52 


6.5 






004 








0.40 2 


0.38 




Sweet .... 




1.4 


1.7 




006 










0.21 


0.32 





Fermented liquors, cider and wines, are beverages in which 
the alcohol is formed as the result of direct fermentation of 
fruit juices. Cider is the fermented juice of the apple. It 
contains from 3 to 8 per cent, of alcohol.. Sweet cider is the 
freshly expressed juice and contains only small amounts of 
alcohol. Perry, or pear cider, is made from the pear. 

^iastatic action complete in ten minutes. 2 As malic acid. 



260 FOODS VALUABLE FOR SALTS, WATER, ETC. 

Wines. — The term wine is customarily used to designate 
the fermented juice of the grape. A number of wines are to 
be had which differ particularly in their method of prepara- 
tion and to a certain extent according to the country or 
locality in which they are prepared. 

Classification of Wines. — A number of terms are used to 
express the type or quality of wines. 1 With regard to the 
method of preparation we have: Natural wines, wines which 
are prepared from the juice of the grape as expressed and to 
which no sugar or alcohol has been added, e. g., hock and 
claret; and fortified wines, to which alcohol has been added, 
usually before the natural fermentation is completed, e. g., 
Madeira, sherry, port. According to the intrinsic prop- 
erties of wines we have the non-effervescing or still wines 
which contain little dissolved carbon dioxide; effervescing or 
sparkling wines, more or less heavily charged with carbon 
dioxide (a) from natural fermentation of added sugar in the 
corked bottles — champagne; or (b) artifically charged with 
carbon dioxide; red wines, Burgundy and Bordeaux wines 
or claret; white wines, e. g., Rhenish and Moselle wine and 
sauternes; dry wines, in which the sugar has been exhausted 
by fermentation; and sweet wines, which possess a consider- 
able amount of unfermented sugar and to which sugar is 
often added. 

Of the different varieties of wines champagne is an effer- 
vescing selected, sweet, white wine fortified with sugar mixed 
with brandy. It contains 8 to 10 per cent, of alcohol; claret 
is a light red wine somewhat acid and astringent, contains 
very little sugar, is high in volatile ethers, alcohol 8 to 13 
per cent. ; Madeira is a strong white wine generally fortified 
with alcohol and possesses a rich, nutty, aromatic flavor, 
alcohol 17 to 20 per cent.; sherry, a Spanish wine, is a sweet 
wine sometimes fortified with alcohol, deep amber colored, 
slightly acid and possesses much fragrance, alcohol 8 to 20 
per cent.; hock, German wines, are white wines mildly acid, 
alcohol 9 to 12 per cent.; port, an astringent wine, always 
fortified with alcohol, dark purple in color, alcohol 15 to 18 
per cent. 

Malt Liquors (Beer, Ale, Porter, Stout). — Malt- liquors 
are made by the alcoholic fermentation of malt with hops; 
other grains are sometimes added. To obtain the sugar 
from which the alcohol is to be formed, grain is malted; that 
is, it is permitted to sprout. In the process of sprouting, 

^he particular mode of preparation and more specific details of their compo- 
sition may be found by consulting such books as, Leach: Food Inspection and 
Analysis, New York, 19 13. 



BEVERAGES 261 

starch is transformed in part into soluble sugars, particu- 
larly maltose; the quantity of the enzyme, diastase, formed 
is often sufficient to change the starch of added grains, rice, 
corn, etc., to a considerable extent. The sprouting process 
is stopped at the proper point and the germinating mass is 
dried. The temperature at which the malt is dried deter- 
mines to a large extent the depth of color of the final product; 
higher temperatures give the darker beers. In some cases 
caramelization of the starch is permitted as in stout. To 
complete the conversion of the starch the dried malt and 
admixed grain, if there be any, are crushed and mixed with 
water to permit the diastase to continue its action. The 
saccharine liquor or wort is concentrated, mixed with hops 
and a selected yeast and permitted to ferment. The nature 
of the yeast added for the alcoholic fermentation is a matter 
of great importance in the production of good malted liquors. 
After fermentation has proceeded to the proper stage the 
beer is drawn off from the greater portion of the yeast and 
stored in casks or vats for an after-fermentation. When 
this process is completed the liquor is clarified and stored in 
casks or bottles. 

Of the different varieties of malt liquor we have beer, pre- 
pared as above without special modification; ale, essentially 
a light colored beer which usually contains more hops than 
beer; porter, a dark ale, and stout. The latter are pre- 
pared from roasted, partially caramelized malt. Such 
liquors are dark colored, usually heavy, and contain consider- 
able quantities of dextrin and starch. 

Malt liquors contain in addition to water, alcohol, and 
sugar, a variety of substances formed in the processes of 
malting and fermentation. Of these the carbon dioxide, 
which produces the effervescence, the volatile oils and the 
bitter principles which contribute to the taste are the most 
important; certain nitrogenous substances, chiefly peptone 
and amino-acids are also present. 

Malt Extracts. — True malt extracts are free from alcohol 
and contain the soluble principles of malt. Such extracts 
have a high percentage of sugar, maltose, 48 to 70 per cent., 
a certain proportion of* dextrin, 2 to 16 per cent., and a high 
diastatic activity. Many of the malt extracts sold have been 
found to have the general characteristics of beer. Some 
have been analyzed which contained approximately from 2 
to 9 per cent, of alcohol. Such extracts have no diastatic 
activity and their nutritive value depends essentially upon 
the sugar content, which is in many cases low. These ex- 
tracts should not be compared with the U. S. P. malt extract 







U. S. P. 


Minimum. 


(for 


comparison) 


2.52 






5-39 




76.6 


0. 14 




1.2 


o.34 




3-1 


4.84 






1. 41 




65-4 


2.03 




6.9 



262 FOODS VALUABLE FOR SALTS, WATER, ETC. 

described above. The following table gives the composition 
of commercial malt extracts in comparison with the U. S. P. 
extract. 

Analyses of twenty-one samples of commercial prepara- 
tions sold as malt extract gave the following maximum and 
minimum values: 1 

Commercial Preparations. 

Maximum. 

Alcohol 9. 11 

Extract 15 .32 

Ash 0.37 

Nitrogenous constituents, protein 1 .09 

Sugar solids x 4 04 

Maltose 11 . 17 

Dextrin 5.80 

Distilled Liquors. — Distilled liquors, as the name implies, 
are the product of the distillation of fermented liquors. By 
this process a liquor is obtained which is high in alcohol and 
contains in addition certain of the higher boiling-point alco- 
hols, their esters, and acids which pass over with the alcohol. 
The distillation process is usually repeated and the inter- 
mediate portions taken for the best liquors, while the first 
and last distillates yield inferior products. The liquor ob- 
tained is harsh to the taste and must be stored for a time in 
casks and aged, to soften and refine the flavor. 

Whiskey is the product of the distillation of fermented 
grains, usually mixtures of corn, wheat, and rye, which has 
been stored in casks for at least four years, alcohol content 
approximately 30 to 50 per cent. Brandy is the aged product 
of the distillation of fermented grape juice or wine. The 
term is sometimes applied to the distillation of the fermented 
juice of other fruits, alcohol 20 to 50 per cent. Cognac is a 
brandy distilled in certain parts of France. Rum is the dis- 
tillation from fermented molasses or cane juice, usually dis- 
tilled twice and stored for a long time. Gin is an alcoholic 
liquor flavored with the volatile oil of the juniper berry; 
other aromatic substances are sometimes used, such as cori- 
ander, anise, cardamom, orange-peel, fennel. Gin is water- 
clear and is kept in glass and not wood as are the other dis- 
tilled liquors, alcohol 27.5 to 42.5 per cent. 

Liqueurs and cordials are manufactured beverages con- 
taining a large proportion of alcohol, sugar, and essential 
oils. They are often highly colored. 

^onn. Agr. Exp. Sta. Report, 19 14, p. 254. 



PART III. 

FEEDING IN INFANCY AND 
CHILDHOOD. 



BREAST 



CHAPTE R XVI. 

FEEDING— FEEDING NORMAL 
ABNORMAL CHILDREN 

WOMAN'S MILK. 



AND 



Milk is a secretion of the mammary glands, but a few of 
its normal constituents are the result of transudation from 
the mother's blood. The composition of human milk is 
qualitatively similar to cow's milk, but quantitatively quite 
different. Furthermore, women's milk varies in amount 
and composition at different times, depending upon the 
length of time which has elapsed since the labor, upon the 
health of the mother, and upon whether or not the breasts 
are completely emptied at each nursing. 

Colostrum. — Colostrum is the term applied to the milk 
secreted during the first few days (i to 12) postpartum, be- 
fore lactation is well established. Czerny and Keller in- 
clude under this term all milk that shows evidence of ab- 
sorption. Colostrum is deep yellow in color, has an average 
specific gravity of about 1.040, a strongly alkaline reaction, 
and is coagulated by heat. Its composition varies consider- 
ably. The following table gives the average composition of 
five early colostrums compiled by Holt, Courtney and Fales: 1 



Average Composition of Five Colostrums (i to 12 Day 



Fat . . 
Lactose . 
Protein . 
Ash . 
Total solids 



83 

59 

25 

3077 

42 



The fat droplets of colostrum are more unequal in size 
than those of milk. Colostrum contains, besides the usual 
constituents of milk, many large nucleated granular bodies, 
called "colostrum corpuscles," which are about five times as 
large as ordinary leukocytes, contain many small fat drop- 

'Amer. Jour. Dis. Child, 1915, x, 229. 
263 



264 FEEDING IN INFANCY AND CHILDHOOD 



lets and have ameboid motion. They are present in large 
numbers for the first few days, rapidly disappear after lacta- 
tion is well established, but reappear when lactation is in- 
terrupted. Czerny considers them leukocytes that appear 
when the breasts are not sufficiently emptied of milk and help 
in the absorption of fat. 

General Characteristics of Woman's Milk. — Woman's 
milk is bluish- white in color, odorless and sweet to taste. 
Microscopically it shows many fine fat droplets which are 
smaller than most of the fat droplets in cow's milk. It con- 
tains a few epithelial cells and leukocytes. The number of 
the latter is greatly increased when there is any inflamma- 
tion of the breast. Its average specific gravity is 1.031, but 
it may vary between 1.026 and 1.036. 

Woman's milk is neutral or slightly alkaline in reaction; 
and is amphoteric. The latter condition is due to the pre- 
sence of both mono- and diphosphates, the former being 
acid and the latter alkaline in reaction. 

The casein of woman's milk does not coagulate in such 
large clots as the casein of cow's milk. On the addition of 
acetic acid a fine flocculent precipitate is formed. Rennin 
alone does not coagulate it. 

Quantity. — The quantity of milk secreted increases rapidly 
for the first six to eight weeks, after this more slowly. To a 
certain extent the quantity is governed by the demands of 
the infant. A large vigorous infant will obtain more milk 
than a smaller, less vigorous infant. Furthermore, a wet- 
nurse will secrete more milk while nursing two or three in- 
fants than while nursing only one. 

The following table gives the average daily amount of 
milk drawn by an infant (from Czerny and Keller) : l 





Average we 


ght 


The calcu- 




Average weight 


The a 


ilcu- 




Age of breast-fed 


lated day's 


A.ge 


of breast-fed 




lated day's 


in infants according 


amount of 


in 


infants according 


amount of 


weeks. to 


Camerer. 




milk. 


weeks. 


to Camerer 




milk. 




gm. 


lb. and oz. 


gm. 


oz. 




gm. lb. and oz. 


gm. 


oz. 


I 


3410 


7 


2 


291 


9-7 


14 


5745 1 1 


15 


870 


29.0 


2 


3550 


7 


6 


549 


18.3 


15 


595o 12 


6 


878 


29 


3 


3 


3690 


7 


11 


590 


19.7 


16 


6150 12 


13 


893 


29 


8 


4 


3980 


8 


5 


652 


21.7 


17 


6350 13 


4 


902 


30 


1 


5 


4115 


8 


9 


687 


22.9 


18 


6405 13 


5 


911 


30 


4 


6 


4260 


8 


14 


736 


245 


19 


6570 13 


11 


928 


30 


9 


7 


4495 


9 


6 


785 


26.2 


20 


6740 14 


1 


947 


31 


6 


8 


4685 


9 


12 


804 


26.8 


21 


6885 14 


5 


956 


31 


7 


9 


4915 


10 


4 


8i5 


27 .2 


22 


7000 14 


9 


958 


31 


9 


10 


5055 


10 


9 


800 


26.7 


23 


7150 14 


14 


970 


32 


3 


11 


5285 


11 




808 


26.9 


24 


7285 15 


3 


980 


32 


7 


12 


5455 


11 


6 


828 


27.6 


25 


7405 15 


7 


990 


33 





13 


5615 


11 


11 


852 


28.4 


26 


75oo 15 


10 


1000 


33 


3 



1 Des Kindes Ernahrung, Ernahrungsstorungen und Ernahrungstherapie, 
Leipzig und Wien, x. 353. 



WOMAN'S MILK 265 

Composition. — Woman's milk varies widely in its composi- 
tion. Its principal ingredients are the same as those in 
cow's milk: namely, fat, lactose, protein, salts and water. 
The average composition is as follows : 

Average Composition of Woman's Milk. 

Fat 350 

Lactose . 7.00 

Protein . . . . 1 . 50 

Salts 0.21 

Water 87 .29 

Holt, Courtney and Fales 1 divide lactation into four 
periods: the colostrum period (1 to 12 days), the transition 
period (12 to 30 days), the mature period (1 to 9 months), 
and the late period (10 to 20 months), and give the follow- 
ing figures as averages for these periods: 

Percentage Composition of Woman's Milk. 

No. of Pro- Total 

Period. analyses. Fat. Sugar. tein. Casein. Albumin. Ash. solids. 

Colostrum, 1-1 2 days 5 2.83 7.59 2.25 .. .. 0.3077 1342 

Transition, 12-30 days 6 4.37 7.74 1.56 .. .. 0.2407 13-39 

Mature, 1-9 mos. . 17 3.26 750 1.15 0.43 0.72 0.2062 12.16 

Late, 10-20 mos. . 10 3.16 7.47 1.07 0.32 0.75 0.1978 12.18 

The sugar content remains practically constant throughout 
the entire period of lactation. Protein and ash are highest 
in the colostrum period and fall quite rapidly to the mature 
period, after which they vary little. The fat content is low- 
est in the colostrum period, rises rapidly in the transition 
period, and then falls in the mature period. These analyses 
of Holt, Courtney and Fales are particularly important, be- 
cause many of their specimens were entire twenty-four-hour 
amounts. 

Fat. — The fat in human milk is held in permanent emul- 
sion. The average percentage of fat is 3.5 or 4 per cent., 
but it may vary from 0.75 to 10 per cent. As a rule the 
amount of fat in the milk increases from the beginning to the 
end of each nursing. 

Volatile fatty acids form 2.5 per cent, of the total fat of 
woman's milk and 27 per cent, of the total fat of cow's milk. 
Oleic acid forms about 50 per cent, of the non-volatile fatty 
acids, the remainder being composed of myristic, palmitic 
and stearic acids. 

Lactose. — The percentage of lactose in woman's milk is 
more constant than that of the other constituents, being 
about 7 per cent, which is nearly twice that of cow's milk. 
It is in solution. 

1 Loc. cit., 239 



266 FEEDING IN INFANCY AND CHILDHOOD 



Protein. — The proteins of woman's milk comprise casein, 
which is insoluble in water, and lactalbumin and globulin, 
which are soluble in water. Besides these there are some 
nitrogenous substances which do not give the protein reac- 
tions. A large part of the latter is supposed to be urea. 
There is considerable difference of opinion as to the propor- 
tions of these substances. According to Talbot the probable 
division of the total nitrogen is as follows: " Casein 41 per 
cent., lactalbumin and globulin 44 to 39 per cent., residual 
nitrogen 15 to 20 per cent." Thus the lactalbumin and glo- 
bulin form a much larger part of the total protein in woman's 
milk than they do in cow's milk. 

Salts. — The average ash content of woman's milk is less 
than a third that of cow's milk, being only 0.21 per cent. 
The following table gives the average salt content of 100 c.c. 
of woman's milk according to Holt, Courtney and Fales: 1 



Averages for the Different Periods. 



No. of Total 
analyse 

Colostrum, 1-12 days 5 
Transition, 12-30 days 6 
Early mature, 1-4 

months ... 9 
Middle mature, 4-9 

months ... 8 
Late milk, 10-20 

months ... 10 



ash. 

•3077 
.2407 


CaO. 

.0446 

.0409 


MgO. 
.OIOI 
.OO57 


p 2 o 5 . 

.04IO 
.0404 


Na 2 0. 

•0453 
•0255 


K 2 0. 

.0938 • 
.0709 . 


.2056 


.0486 


.0082 


.0342 


.0154 


• 0539 • 


.2069 


.0458 


.0074 


•0345 


.0132 


. 0609 . 


.1978 


.0390 


.0070 


.0304 


•0195 


•0575 • 



CI. 

0568 
0580 

0351 
0358 
0442 



The average percentage composition of the ash by the 
same investigation is as follows: 

Average Percentage Composition of Ash for the Different Periods. 

CaO. MgO. P.J0 5 . Na 2 0. K 2 0. CI. 

. . . . 14.2 3.5 12.5 13.7 28.1 20.6 

17.0 2.4 16.9 IO.9 30.8 22.9 

• • • • 23.3 3.7 

.... 19.8 3.6 



Colostrum . 
Transition . 
Mature 
Late . . 



12.5 
16.9 
16.6 
15-5 



7.2 
10. 1 



28.3 
18.8 



16.5 
22.3 



Iron. — The iron content of woman's milk is about three 
times that of cow's milk. This makes the iron intake of an 
infant fed on diluted cow's milk much lower than that of a 
breast-fed infant. 

Phosphorus.— Woman's milk contains much less phos- 
phorus than cow's milk. About three-fourths of the phos- 
phorus of woman's milk is in organic combination, as against 
one-fourth of that of cow's milk. 

Salts of Woman's and Cow's Milk. — The total ash content 
of cow's milk is about three and one-half times that of wo- 
man's milk. The proportion of the different salts is quite 

x Am. Jour. Dis. Child., 1915, x. 243, 245. 



CaO. 


MgO. 


p 2 o 5 . 


Na,0. 


KoO. 


CI. 


23-3 


3-7 


16.6 


7.2 


28.3 


16.5 


23-5 


2.8 


26.5 


7.2 


24.9 


13-6 



WOMAN'S MILK 267 

similar, the chief differences being in the larger amount of 
iron and the smaller amount of phosphorus in woman's 
milk. Holt, Courtney and Fales 1 give the average composi- 
tion as follows: 

Comparison of the Percentage Composition of the Ash of Woman's 
and Cow's Milk. 

Mature woman's milk 

Cow's milk 23.5 

Bacteria. — A few bacteria, usually staphylococci, are found 
in the milk of healthy women. Typhoid bacilli have been 
demonstrated in the milk of a woman ill with typhoid fever. 
Syphilis can probably be transmitted by the milk even when 
the breasts are apparently normal. Pathogenic bacteria may 
be present in the milk when the mother is suffering from a 
local infection of the breast or a general sepsis. 

Drugs. — Some drugs are excreted in woman's milk. They 
are alcohol, bromides, iodides, salicylates, mercury, calomel, 
antipyrin, arsenic, urotropin, the saline cathartics and sal- 
varsan. Probably morphine and atrophine also are ex- 
creted in woman's milk. Most of these are found in very 
minute amounts. 

Nervous Impressions. — Any severe, acute or prolonged 
nervous strain may so alter the mother's milk as to seriously 
upset the infant. For this reason it is important that a 
nursing mother should lead a quiet life and avoid all nervous 
strain and excitement. Women that are prone to nervous 
disturbances, as hysteria, are seldom able to nurse their 
infants successfully. 

Menstruation. — Menstruation does not, as a rule, seriously 
affect the milk supply. Not infrequently the infant is un- 
comfortable and has undigested stools at the onset. Only 
rarely is the disturbance more serious and prolonged. 

Pregnancy. — If a nursing mother becomes pregnant her 
milk rapidly deteriorates both in quantity and quality. 
Weaning is imperative. 

Transmission of Immunity. — A mother, who is immune 
to one or more of the infectious diseases, usually transmits a 
varying degree of immunity to her offspring. Some of the 
immune bodies enter the fetus by way of the placenta but 
the work of Famulener 2 would seem to show that a greater 
number pass from the mother to the infant in the colostrum 
which is secreted in the first few days. He, as well as others, 
demonstrated immune bodies in the colostrum of immune 

l Am. Jour. Dis. Child., 1915, x. 246. 

2 Studies from Research Lab. Dept. Health of New York City, 191 1, vi, 199. 



268 FEEDING IN INFANCY AND CHILDHOOD 

mothers. Furthermore the concentration of immune bodies 
in the colostrum was greater than in the mother's blood 
serum at the same time. Milk of a later period contained a 
much smaller number of immune bodies. After taking the 
colostrum of such mothers for several days, the concentra- 
tion of immune bodies in the blood serum of the young 
animals was greatly increased. There seems to be no reason- 
able doubt but that new born infants can absorb such im- 
mune bodies from the digestive tract. Immune bodies with 
homologous proteins, such as are present in milk of the 
same species, are more readily absorbed than those associated 
with heterologous proteins as in milk of other species. These 
facts would emphasize the importance of young infants 
nursing at least for a few days. 

Diet. — Within narrow limits the amount and composition 
of the milk may be altered by changes in the diet. The 
best results are obtained when the mother has been under- 
fed, and the milk is abundant but poor in quality, especially 
in fat. Increasing the diet generally, but especially the fat 
and carbohydrate, will usually increase the fat content of 
the milk. When the fat is too high, reducing the fat and 
carbohydrate in the diet and increasing the mother's exer- 
cise will usually reduce the fat. Low protein can be over- 
come by increasing the diet when the mother has been under- 
fed, but is rarely influenced when the mother is already re- 
ceiving a plentiful diet. Reducing the diet and increasing 
the exercise will sometimes reduce a too high protein. The 
percentage of lactose in woman's milk is more constant than 
that of either the fat or the protein and is little influenced by 
diet. An increase in the ,fluid intake will often increase the 
quantity of milk. 

BREAST FEEDING. 

The simplest and best way to feed an infant is to nurse it. 
No artificial food has been evolved which gives nearly as 
uniformly good results. Therefore every mother that can do 
so should nurse her infant. The great value of breast feed- 
ing as compared with artificial feeding is proved by the 
much higher mortality rate among artificially fed infants. 
Another factor of importance is the greater frequency of 
rickets among the artificially fed. With premature infants, 
full-term infants that are feeble and under-developed, and 
the occasional infant that is unable to digest cow's milk, 
breast milk is essential. Among the poor there is very little 
opposition to breast feeding, unless the mother is the wage- 
earner and has to be away from home during the day, and 



BREAST FEEDING 269 

even these mothers usually nurse their infants night and 
morning. Among the well-to-do the mothers are less fre- 
quently able to nurse their infants and they find the fre- 
quent nursings and. especially the restrictions which nursing 
places upon their time very irksome. 

Contra-indications for Breast Feeding. — The most fre- 
quent contra-indication is insufficient milk, but every effort 
should be made to increase the amount of milk before re- 
sorting to artificial feeding. 

Another important contra-indication is serious illness of 
the mother, as tuberculosis, typhoid fever, puerperal fever 
and mastitis. When a nursing mother develops an infec- 
tious disease of short duration, as tonsillitis, she may stop 
nursing during the febrile stage and resume it later. The 
breasts should be emptied two or three times a day by mas- 
sage and the breast pump. Many women resume nursing 
in this way after intervals of as long as two weeks. 

Frequently an infant is taken from the breast of a healthy 
mother and given a cow's milk mixture because he does not 
thrive or has indigestion. If the amount and quality of the 
mother's milk is insufficient and cannot be improved by diet 
and regulation of her mode of living, there is nothing else to 
do. When, however, the supply of milk is ample and the 
quality good, every effort should be made to adapt it to the 
infant before beginning artificial feeding, and in only rare 
instances is this impossible. 

Occasionally a nursing mother will become pregnant. 
When this occurs her milk deteriorates rapidly in amount 
and quality. At first the infant stops gaining, later he loses 
weight. Artificial feeding should be begun at once. 

Intervals of Nursing. — Formerly an infant was nursed 
whenever he cried and appeared hungry, and this is today 
the usual procedure among the ignorant. Many such in- 
fants thrive and gain steadily, but they are usually irritable 
and frequently upset the entire household. Habits are soon 
formed by infants, and regularity is an important one. Six 
to eight hours after birth the infant is allowed to nurse 
for five minutes. After this the nursings are repeated every 
six hours for the first two days. When the breasts begin to 
secrete milk, which usually occurs on the third or fourth day, 
the intervals are shortened to three hours, with one nursing 
omitted at night. At the same time the length of time that 
the infant is allowed to nurse is increased to ten or fifteen 
minutes. 

From this time to the third month the infant should nurse 
at 6, 9, 12, 3, 6, 9, and once during the night, usually about 



270 FEEDING IN INFANCY AND CHILDHOOD 

2 A. M. Always after the fourth month and occasionally 
earlier the night feeding may be stopped. It is well to stop 
this feeding as soon as possible, as the long undisturbed sleep 
is good for both the mother and infant. After the fifth month 
the intervals may be lengthened to four hours and the num- 
ber of nursings reduced to five. The hours will now be 6, io, 
2, 6, io. During the day the time of feeding should be 
strictly adhered to. At night, however, the time may be 
varied considerably to suit the convenience of the mother. 
For example, occasionally an infant will wake at 5 A. m. He 
may be fed then instead of at 6 a. m., but he should not re- 
ceive his second bottle before the regular time, that is at 
9 or 10 A. M., depending on whether he is on a three or four 
hour schedule. The time for giving the evening bottle may 
vary between 9 and 12 p. m. When the night feeding is 
dropped, it shortens the interval between the last evening 
feeding and the first morning feeding if the evening feeding 
is given at 11 P. M., instead of 9 or 10 P. M. The infant is, 
therefore, more apt to sleep until the usual time for the morn- 
ing feeding. 

These intervals are somewhat longer than those frequently 
recommended for the first few months. Feeble and prema- 
ture infants frequently do better when nursed every two or 
two and one-half hours. Normal infants, however, gain 
just as rapidly on three-hour intervals, which have the advan- 
tages of allowing the stomach to empty more completely 
between nursings, giving the mother more freedom and 
lessening the likelihood of cracked nipples. Even four-hour 
intervals from the beginning are recommended by some 
physicians. 

Length of Each Nursing. — After lactation is well estab- 
lished, most infants will nurse fifteen to twenty minutes each 
time for the first few weeks. Later they will frequently be 
satisfied in ten minutes. An infant should never be allowed 
to nurse a few minutes, play a few minutes and then nurse 
again. They should be taught from the beginning to nurse 
steadily, with an occasional rest, until they are through. An 
infant should never be allowed to sleep in the same bed with 
his mother, as this encourages him to nurse frequently during 
the night. An infant should seldom be allowed to nurse 
more than twenty minutes. If he is not satisfied by this 
time, he is either taking too much or the supply of milk is 
scanty. Weighing him before and after nursing will settle 
this point. 

Mother's Diet and Exercise. — A nursing mother should 
take a plentiful diet of easily digested food, with some extra 



BREAST FEEDING 271 

fluid, as milk, egg and milk, cocoa or gruel in the middle of 
the morning and afternoon and before going to bed at night. 
If preferred the extra milk may be taken after each meal. 
Besides this she should drink a plentiful supply of water. 
She should avoid all articles of diet that are highly spiced, 
very rich or difficult of digestion, such as peppers, pickles, 
relishes, vinegar, rich puddings and sauces, lobster, crabs, 
Welsh rarebit, and excessive amounts of coffee, tea and alco- 
hol. Most nursing mothers can take moderate amounts of 
raw or cooked fruits and vegetables. Occasionally, however, 
even moderate amounts of fruit, especially the more acid 
ones such as grapefruit or green vegetables, particularly 
tomatoes and onions, will cause colic and indigestion in the 
infant. When this happens the particular fruit or vegetable 
causing the trouble should be omitted from the diet. If it is 
impossible to determine which fruit or vegetable is causing 
the trouble, it is well to omit all fruit and green vegetables 
until the infant is normal again. Then they may be resumed 
one at a time, the infant being watched for any return of the 
symptoms. In this way the cause of the disturbance can 
usually be identified and so eliminated. 

A nursing mother should be relieved, as far as possible, of 
all strenuous work and exercise. Moderate exercise, on the 
other hand, is essential for her health and counteracts the 
tendency to too rich milk. Walking in the open air is one of 
the best forms of exercise. 

More essential even than exercise is sufficient rest. She 
should have at least one long period of sleep during the night, 
and at least two hours of sleep during the day. The longer 
intervals between nursings and the early stopping of the 
night feeding all help toward this end. 

It is possible to influence the quantity and composition of 
the mother's milk to a considerable extent by altering her 
diet and mode of living. 

If the quantity is too small the mother's diet should be 
increased, especially the amount of milk, eggs, and meat. 
Also her water intake should be increased. Her exercise 
should be limited and sufficient rest assured. Frequently 
relieving her of the physical and mental strain of caring for 
the infant helps a great deal. If she is anemic, run down or 
unable to take sufficient food because of lack of appetite, 
appropriate medication is indicated. 

If the milk is too rich, which usually means a high fat and 
protein content, lessening the mother's diet (especially meat, 
eggs and milk), increasing the amount of water which she 
takes, and increasing her exercise will usually reduce the fat 



272 FEEDING IN INFANCY AND CHILDHOOD 

content of the milk. At the same time the infant may be 
given one-half ounce of sterile water before each breast feed- 
ing and the length of the nursing reduced or the interval 
between nursings increased. 

When the milk is poor in quality, that is, has a low fat 
content, the procedure is the same as when it is insufficient, 
except that it is more important to increase the solids in the 
mother's diet than the fluids. 

It is easier to correct an abundant supply of overrich milk 
than an insufficient supply of milk which is poor in quality. 

Vomiting.— Most infants, whether breast or bottle fed, will 
occasionally regurgitate small amounts, from a few drops to a 
teaspoonful or two. This is to be expected and need cause 
no alarm. When, however, a breast-fed infant vomits large 
amounts after a good many feedings, something is wrong 
either with the milk or the method of handling the infant. 
The possibility of pylonc stenosis must always be kept in 
mind. Not infrequently it is due to the infant's efforts to 
rid himself of air swallowed during the nursing. This is apt 
to happen when the infant is placed in his bed immediately af- 
ter nursing. C. PL Smith 1 has demonstrated that under 
these circimstances the gas is water-locked in the stomach, 
and an endeavor to belch it on the part of the infant is sure 
to cause some vomiting. If the infant is held erect for a 
minute or two after nursing he will belch the gas without 
losing any milk. 

Too much milk or too high fat will cause vomiting. The 
amount can be determined by weighing before and after 
nursing. If the infant is taking too much, the length of the 
nursing should be shortened. If analysis of the breast milk 
shows a too high fat content the mother's diet should be cut 
down slightly, especially the solid food, and her water intake 
and exercise increased. Also the infant may be given one- 
half ounce of sterile water before each nursing. 

Gas and Colic. — Both gas and colic occur much less often 
when an infant is breast fed than when he is artificially fed. 
The usual cause of gas has been explained in the previous 
section on vomiting. Occasionally certain articles in the 
mother's diet will cause colic in the infant. The most fre- 
quent are the raw' acid fruits and green vegetables. The 
method of handling this situation has been explained in the 
section on the mother's diet. 

Normal Stool. — A normal breast fed infant usually has 
from one to four stools a day. The stools are soft, almost 
never formed, and yellow in color. They are not uniform 

'Am. Jour. Dis. Child, 1915, ix, 261. 



MIXED FEEDING 273 

in consistency, like the stool of an artificially fed infant, but 
contain a varying number of small, soft masses, each about 
a millimeter in diameter, which are light in color. Their 
reaction is slightly acid. Not infrequently an infant, that 
is gaining regularly and is comfortable, will have decidedly 
abnormal stools. This in itself is not an indication for stop- 
ping nursing. 

Abnormal Stools. — Constipation is unusual in the breast- 
fed infant unless the milk is insufficient either in quality or 
quantity. 

Loose, too frequent stools, often containing considerable 
mucus accompanied by colic may occur when the mother is 
menstruating, after an indiscretion in diet on the mother's 
part, when the mother is suffering from an acute infection, 
or when the milk is not adapted to the particular infant. All 
but the last condition are transient and easily righted. If 
the milk is at fault the first thing to do is to determine the 
quantity taken by the infant and the composition of the milk. 
The quantity taken can be determined by weighing the infant 
before and after nursing. If the quantity is too great the 
length of each nursing should be shortened. 

If the composition of the milk is wrong an endeavor should 
be made to correct the fault by changing the mother's diet 
and routine as is explained in the section on the mother's 
diet. This is at times impossible, especially when the milk 
is both scanty and poor in quality. Unless some improve- 
ment is made within two weeks it is rarely wise to persist 
any longer. 

MIXED FEEDING. 

When a woman has an insufficient supply of milk for her 
infant, supplementary feedings of cow's milk may be used. 
This is mixed feeding, and it is indicated whenever the breast 
milk is of good quality but insufficient in amount to properly 
nourish the infant. One of two procedures may be employed, 
either small bottle feedings may be given after each breast 
feeding, or bottle feedings may be substituted for some of the 
breast feedings. If the former method is followed the in- 
fant is given only one breast at a nursing. The amount of 
breast milk obtained is calculated by weighing the infant 
before and after nursing. Then a sufficient bottle feeding 
is given to make up the proper amount. As a rule it is not 
necessary to weigh the infant before and after nursing for 
more than a few days. If the second method is chosen, one, 
two or three of the breast feedings are omitted and a full 
bottle feeding given at these times. At the breast feedings 
18 



274 FEEDING IN INFANCY AND CHILDHOOD 

it is best to give the infant both breasts each time, as other- 
wise the long intervals between nursings tend to diminish 
the amount of milk secreted. It is rarely possible to keep 
up the supply of milk if the infant nurses less than four 
times in each twenty-four hours. There is a distinct advan- 
tage in always giving one bottle feeding a day to all breast- 
fed infants after the third month. By so doing they become 
accustomed to taking the bottle and their digestion becomes 
adapted to cow's milk. Furthermore it allows the mother 
one long interval during the day in which she may rest or 
be out of doors. If at any time it becomes necessary to 
wean the infant suddenly it can be accomplished with much 
less likelihood of disturbance. 

In beginning mixed feeding a relatively low formula should 
be used at first. A three-months-old infant should begin 
with about a 6 in 20 and a six-months-old infant with an 8 
in 20 mixture. The full amount lor the infant's age may be 
given from the beginning. The strength of the formula may 
be increased quite rapidly, about an ounce of milk being added 
every three days, provided there are no evidences of indi- 
gestion, until the strength of the formula is proper for the 
infant's age. 

The advantages of mixed feeding over artificial feeding are 
that it gives the infant a considerable amount of breast milk, 
that it allows the infant to become accustomed to cow's 
milk gradually, and that it simplifies weaning. 

WEANING 

Few women can nurse their infants to advantage after the 
eighth or ninth month, and many have to give supplementary 
feedings long before this. Where it is possible to obtain 
good cow's milk it is a distinct advantage to give the infant 
one bottle feeding a day after the third or fourth month. 
This accustoms the infant to the bottle and greatly lessens 
the difficulty of weaning if the latter, becomes necessary at 
any time. Infants that have never had a bottle feeding 
until they are six months of age or older will frequently 
refuse it absolutely as long as they are given the breast at all 
and sometimes for several days, even after the breast feed- 
ings have been entirely stopped. During this time they lose 
weight rapidly and not infrequently develop considerable 
fever. Little is gained by forcing them to take the bottle 
under these circumstances. The best method is to offer the 
bottle at the regular intervals and take it away if refused. 
They always give in finally. No serious results follow this 



WEANING 275 

method. A three-months infant, on the other hand, soon 
becomes accustomed to taking one feeding from the bottle. 

The indications for early weaning are insufficient milk, 
severe illness of the mother, and pregnancy. When possible 
it is better to wean gradually. If the infant has been taking 
one bottle a day another of the same strength is added and 
after a few days another until all of the breast feedings have 
been stopped. The rapidity with which this is done will 
depend upon the cause of the weaning and the amount of 
milk which the mother has. If the infant is already taking a 
bottle feeding, the other feedings should be of the same 
strength. If the infant has never taken any cow's milk the 
first formula should be considerably weaker than a normal 
artificially fed infant of the same age would be taking. After 
the first few days the strength of the formula should be grad- 
ually increased until the food is sufficient for the infant. 
When it is necessary to stop all breast feedings at once it is 
more important to begin with a relatively weaker formula 
than when the bottle feedings can be gradually substituted. 

When the mother is able to nurse the full eight or nine 
months the process is much simpler. The various foods other 
than milk are added to the diet in the same order and amounts 
as with the artificially fed infant, except that it is not neces- 
sary to make these additions quite as early. When cereal 
is begun, a small amount of cow's milk (i or 2 ounces) diluted 
with an equal volume of boiled water is given with the cereal. 
As the cereal is increased the strength and amount of milk is 
increased. Then one feeding of diluted milk is substituted 
for a breast feeding. If the mother is well and strong and 
has an abundant supply of milk she may be allowed to nurse 
to the twelth or thirteenth month. When this is possible it 
may not be necessary to use bottles at all, the infant being 
weaned directly to the cup. In no normal case should 
bottles be continued after the eighteenth month. 



CHAPTER XVII. 

ARTIFICIAL FEEDING 

FOOD REQUIREMENTS OF THE ARTIFICIALLY FED 

INFANT. 

Energy. — Repeated efforts have been made to formulate 
some law or laws by which the caloric requirements of a 
given infant could be calculated. The first work was based 
entirely upon the body weight. It was soon found that the 
caloric requirement per pound was considerably larger for 
thin infants than for well-nourished infants. Then it was 
suggested that the surface area, and not the body weight, 
was the governing factor. As it is obviously impossible 
actually to measure the surface area of all infants, different 
investigators have worked out formulae by which the sur- 
face area of infants can be calculated. The results obtained 
by this method are more uniform than those obtained where 
the weight alone is considered, but the calculations are too 
complicated to be of practical use in every-day practice. 
Recently it has been suggested that the caloric requirement 
of an infant varies directly with the mass of active proto- 
plasmic tissue in the body. This would explain why a 
thin infant requires more calories than a fat infant of the 
same weight. Unfortunately we have no means of calcu- 
lating the mass of active protoplasmic tissue in any living 
infant. 

Muscular exertion has a marked influence upon the re- 
quirements of the infant. Hard crying may increase the 
energy output by ioo per cent. Thus a very active infant 
always requires more energy than a quiet passive infant. 

For practical use the body weight must be the guide at 
present. The usually accepted requirement is ioo calories 
per kilo or 45 calories per pound of body weight for each 
twenty-four hours from the end of the second week to the 
ninth month. At the same time we must remember that a 
very thin infant will frequently require considerably more 
than 100 calories per kilo, while a very fat infant may gain 
and do well on considerably less. During the first two 
weeks the caloric requirement is considerably less than 45 
calories per pound, averaging only about 30 calories. After 
the eight month the requirement falls to about 40 calories 
per pound. 

276 



FAT 277 

Protein. — Protein is required by the infant to replace that 
lost in tissue waste and for the formation of new tissue in 
growth. This double demand makes the protein require- 
ment of a growing infant relatively greater than that of an 
adult. Furthermore, as the most rapid growth takes place 
during the early months, the protein requirement is greatest 
during these months. Morse and Talbot 1 say, "The aver- 
age protein need of infants is at least 1.5 gram per kilogram, 
or 0.7 gram per pound of body weight. " In order to obtain 
this amount an infant must take nearly an ounce of cow's 
milk per pound of body weight. The generally accepted 
rule of one and a half ounces of cow's milk per pound of body 
weight furnishes considerably more than this amount. 

Almost all cow's milk mixtures contain more protein than 
woman's milk. This is especially true of whole-milk mix- 
tures. The low fat content of the latter makes it necessary 
either to use a very high sugar content or to raise the pro- 
tein considerably above the theoretical requirement in order 
to furnish the necessary calories. Thus the whole milk 
mixtures which are commonly used, contain about \V A 
ounces of milk per pound of body weight. 

Animal protein is more easily digested and more com- 
pletely absorbed than vegetable protein. The protein of 
milk is most readily digested by infants, that of woman's 
milk more easily than that of cow's milk. 

Formerly most of the digestive disturbances of infants 
were attributed to the protein, but of late the tendency has 
been to minimize the importance of protein as a cause of 
indigestion. Some justification for the larger amounts of 
protein frequently fed in cow's milk mixtures is found in the 
smaller amounts of some essential amino-acids in the pro- 
tein of cow's milk. 

Fat. — As fat furnishes approximately twice as many 
calories per gram as carbohydrate or protein, it is a very 
important element in the food, and small variations in the 
fat content of the food have a marked influence upon its 
energy value. In health from 90 to 98 per cent, of the fat 
in the food is absorbed. In digestive disturbances, especi- 
ally those conditions which are associated with diarrhea, a 
much smaller portion of the fat ingested is absorbed. Holt, 
Courtney and Fales, 2 found that from 90.3 to 99.2 per cent, 
of the fat intake was absorbed in healthy breast-fed infants, 
and an average of 91.3 per cent, by healthy infants fed on 
modified cow's milk. In normal infants they found the 

diseases of Nutrition and Infant Feeding, 1915, p. 201. 
2 Am. Jour. Dis. Child., 1919, xvii, 241, 423. 



278 ARTIFICIAL FEEDING 

average fat per cent, of the dried stool to be 34 per cent, 
whether the infant was taking woman's or cow's milk. The 
fat in the stools of breast-fed infants was divided as follows: 
soap fat 43.1 per cent., free fatty acids, 36.7 percent., neutral 
fat 20.2 per cent. In the stools of healthy infants fed on 
modified cow's milk the fat was divided as follows: soap fat 
60.5 per cent., neutral fat 12. 1 per cent. In both groups of 
infants suffering from diarrheal conditions the fat retention 
fell markedly. At the same time the percentage of soap fat 
in the stools fell and the percentage of free fatty acids and 
neutral fat rose. 

There is considerable difference of opinion as to the amount 
of fat which a normal infant's food should contain. Many 
physicians use top milk mixtures and thus keep the fat con- 
tent of the food about twice that of the- protein. Others 
use whole-milk mixtures which make the fat content of the 
food only slightly greater than the protein. Both methods 
have their advantages and disadvantages. An infant fed on 
the higher fat mixtures will gain more rapidly and be satis- 
fied with smaller amounts of food, especially during the early 
months, than one fed on whole-milk mixtures. Further- 
more, the higher fat content permits the use of smaller amounts 
of sugar, which is necessary in feeding infants with an 
intolerance for sugar. The disadvantage is that infants fed 
on high fat mixtures are more apt to have digestive disturb- 
ances. For this reason whole-milk mixtures with their 
lower fat contents are safer in the hands of those with com- 
paratively little experience. 

Carbohydrate.— Sugar. — All milk contains lactose or milk- 
sugar. The sugar content of woman's milk is about 7.5 per 
cent., which is nearly twice that of cow's milk. When cow's 
milk is diluted its sugar content is still further reduced so 
that a considerable amount of sugar has to be added to cow's 
milk mixtures in order to bring their sugar content up to the 
required amount. As a rule sufficient sugar is added to 
make the sugar content of the mixture about 6 percent., 
never more than 7 per cent. An infant fed on woman's 
milk receives slightly more calories in fat than in sugar, 
while an artifically fed infant taking cow's milk mixtures 
receives a rather large part of his calories in the form of 
sugar. 

Three sugars are used in infant feeding, lactose (milk 
sugar), saccharose (cane-sugar), and maltose. All of these 
sugars are disaccharides and in the process of digestion they 
are broken down into monosaccharides. The rapidity with 
which they are absorbed differs and hence their effect upon 
intestinal fermentation and peristalsis. 



STARCH 



279 



Lactose is more slowly absorbed than either maltose or 
saccharose. Its longer stay in the intestinal canal is sup- 
posed to favor the normal fermentation processes and thus 
to hold in check excessive putrefaction. Furthermore, it 
is slightly laxative. For these reasons it is the sugar of 
choice for feeding normal infants. Pure maltose is never 
used in feeding because of its cost. The maltose used is 
always a mixture of maltose with dextrin, the maltose form- 
ing about 50 per cent, of most of the preparations. The 
dextrin content is more variable. The following table taken 
from Morse and Talbot 1 gives the percentage of maltose 
and dextrin in the more common preparations used: 



Food. 
Loflund's nahrmaltose .... 
Mead's dextrimaltose .... 
Neutral maltose (Maltzyme Co.) . 
Loflund's malt soup extract . 
Maltose (Walker-Gordon laboratory) 

Mellin's food 

Malted milk 



Maltose, 
per cent. 

40.OO 
5I.OO 

63 . 00-66 . 00 

58.91 
57io 
58.88 
49.15 



Dextrin, 
per cent. 

60.OO 
47.OO 
8 . 00-9 . 00 

15-42 
30.90 
20.69 
18.80 



In digestion one molecule of maltose is split into two mole- 
cules of dextrose. For this reason it is more rapidly ab- 
sorbed than either lactose or saccharose. This rapidity of 
absorption and the fact that some infants that have devel- 
oped a fermentative diarrhea while taking lactose will 
digest maltose easier than lactose are the chief reasons for 
its use. 

Saccharose (cane-sugar) is split into dextrose and levulose 
in the process of digestion. As the levulose has to be changed 
into dextrose before being absorbed, cane-sugar is more 
slowly absorbed than maltose. Cane-sugar is somewhat 
less laxative than lactose. Furthermore it is much cheaper 
than either of the other sugars. Many normal infants will 
thrive as well pn cane-sugar as on lactose or maltose. Its 
cheapness is its chief recommendation. 

Starch. — Starch is used for two purposes in infant feeding, 
first to prevent the formation of large casein curds in the 
stomach, and second, to increase the strength of the food. 
For the first purpose only a small amount of starch is neces- 
sary, 0.75 per cent, of starch in the food being as effective as 
larger amounts. This amount of starch may be added to the 
food of very young infants. 

After the second month some form of starch is usually 
added to most artificial mixtures. At first a cereal water, 
made by boiling one level tablespoonful of either oat or bar- 
diseases of Nutrition and Infant Feeding, 1915, 194. 



280 ARTIFICIAL FEEDING 

ley flour and a pinch of salt in a pint of water for three-fourths 
of an hour, is used. After the fifth month two level table- 
spoonfuls of flour may be used. Barley water is generally 
believed to be slightly more constipating than oat water. 

Inorganic Salts. — The salt content of cow's milk is about 
three and one-half times that of woman's milk. The result 
is that the ordinary infant fed on diluted cow's milk receives 
a considerably greater amount of salts than a breast-fed 
infant. Furthermore, the relative proportions of the various 
salts differ somewhat in the two feedings, the chief difference 
being in the phosphoric acid. These differences are believed 
to have a considerable influence upon the growing infant, 
especially in disturbances of digestion. 

The following table from Holt 1 gives the relative percent- 
age of the different salts in both cow's and woman's milk. 





Cow's. 


Woman 


CaO 


22.8 


23-3 


MgO 


2.8 


3-7 


P2O5 


27.4 


16.6 


K2O 


24.7 


28.3 


Na 2 


IO.9 


7.2 


CI 


15.5 


16.5 



Water. — The amount of fluid required by an infant in- 
creases rapidly during the first three months and more 
slowly after that. A normal infant usually requires about 
12 ounces at the end of the first week, 24 ounces at the end 
of the first month, 30 ounces by the end of the third month, 
36 ounces by the fifth month, and 40 ounces by the eighth 
month. As a rule the fluid intake is about one-seventh of 
the body weight. As long as all the food is fluid, little addi- 
tional water need be given, but as soon as part of the food is 
solid additional water must be given. 

PROPRIETARY FOODS. 

There are many so-called "infant foods" on the market. 
While these differ greatly in composition they all have cer- 
tain common characteristics. Almost all contain large 
amounts of carbohydrate and small amounts of fat and pro- 
tein. It is well to remember that similar mixtures can be 
produced with the usual ingredients of infant's food without 
using these proprietary preparations. 

They may be divided into four classes: first, those con- 
taining cow's milk; second, those containing considerable 
amounts of maltose and dextrins; third, farinaceous foods; 
and fourth, miscellaneous preparations. 

diseases of Infancy and Childhood, 7th ed., 1916, 150. 



PROPRIETARY FOODS 



281 



Preparations Containing Cow's Milk. — This group includes 
the malted milks, Allenbury's milk food No I. and No. 2, 
and Nestle's food. The basis of all these is milk that has 
been evaporated to dryness. All have considerable quanti- 
ties of carbohydrate added. Their fat content is consider- 
ably higher than that of any of the other classes. 

Preparations Containing Large Amounts of Maltose. — 
Mellin's food which contains about 60 per cent, of maltose, 
is the best example of this group. Mead's dextrimaltose 
No. 1 contains about 53 per cent, of maltose. The malted 
milks are usually included in this group but their fat content 
is a great deal higher, due to the milk used in their manu- 
facture. These foods may be used when maltose is indi- 
cated but should never be used without milk. 

Farinaceous Foods. — This group includes imperial granum, 
Ridge's food, Robinson's barley and oat flour, Brook's bar- 
ley flour, and the Cereo Company's flours. The group 
differs from the first in that they contain almost no fat, and 
from the second in that they all contain considerable amounts 
of unchanged starch. They may be used when it is desir- 
able to add some carbohydrate partly in the form of starch 
to the food. The Cereo Company also furnish an enzyme 
preparation called cereo. By its use from 70 to 98 per cent, 
of the starch is converted into soluble carbohydrates. 

Miscellaneous Foods. — Eskay's albumenized food is made 
from egg albumen and cereals. Peptogenic milk powder is 
largely milk-sugar. 

The following table 1 gives the composition of most of the 
foods mentioned: 





Fat, 




Protein, 


Starch, 


Ash, 


Name. 


per cent. 


Sugar, per cent. 


per cent. 


per cent. 


p. c. 






fmilk l , n TC 1 








Horlick's malted milk 


8.10 


6 7 .95<malt f 49-15 ( 
C dextrin 18.80J 
| milk 42.00] 


15.00 




4.OO 


Allenbury's food No. I 


13.80 


66. 55^ malt 14.00 > 
(dextrin 10. 00] 
fmilk 36.ooi 

70.9V malt 20.00 > 
(dextrin 13.00J 


9.88 




3-98 


Allenbury's food No. 2 


14.20 


9-75 




3-70 
















/milk 6.57^ 

58 qJ Ca T 25 ° ' 
50 '^ malt „„ ,{ 

(dextrin 2 ^ ^\ 








Nestle's food . 


5 -70 


11.94 


20.25 


1-45 



1 The figures for fat, protein, starch and ash in the above table are taken from 
the Report of the Connecticut Agricultural Experiment Station, 19 16, 328. 
Those for sugar are for the most part from Morse and Talbot: Diseases of Nutri- 
tion and Infant Feeding, 1915, 230, 



282 



ARTIFICIAL FEEDING 





Fat, 






Protein, 


Starch, 


Ash, 


Name 


per cent. 
1.80 


Sugar, per cent. 


per cent. 


percent. 


p. c. 


Mellin's food . 
Mead's dextrimaltose 


\ malt 
79 • 57 1 dextrin 
~„ ~~\ malt 
93 00 j dextrin 


58.88/ 
20.69C 


II. 31 




4-45 


No. i . . • . . 




52 . 00 / 
41. oof 






2.00 






f dex- 


) 








Imperial granum . 


O.50 


1 . 8o< trose 
(_ dextrin 


0.42 V 
1.38J 


13-88 


72.79 


0.50 


Ridge's food' . 


0-33 


2.96 




10.31 


70 -93 


0.75 


Robinson's barley 


1.40 


2.92 




6-75 


70.20 


0.85 


Brook's barley 


1.03 


3-48 




8.69 


68.51 


0.88 


Cereo barley . 


2.03 


5.20 




14.88 


58.39 


1.48 


Cereo oat .... 


6.40 


2.36 




16.44 


56.31 


2-53 


Eskay's food . 


1.28 


55 - 82 j dextrin 


54-i2( 
1. 70 J 


7-75 


31-95 


1-58 



ARTIFICIAL FEEDING. 

None of the rules for the artificial feeding of infants so far 
advanced apply to the newborn, because these infants are 
unable to digest cow's milk in sufficient strength or amount 
to satisfy completely their theoretical requirements. Hence 
we are forced to begin with such dilutions and amounts as 
experience has taught us are safe, and increase them as rap- 
idly as the infant's digestion will allow, until a sufficient 
amount of food is taken. After that the food may be calcu- 
lated with reference to the caloric requirement. 

For the first twenty-four to forty-eight hours many in- 
fants vomit repeatedly, especially when given any fluid. 
During this time it is best to give boiled water or a 5 per 
cent, solution of lactose in boiled water. One or two ounces 
should be given every three hours. After thirty-six hours, 
provided the vomiting has ceased, a weak solution of milk 
may be given. Although many still use top-milk mixtures, it 
is safer to use whole-milk dilutions with a small amount of 
lactose added. Infants fed on whole-milk mixtures do not 
gain as rapidly at first as those fed on top-milk mixtures. 
On the other hand, they are much less likely to become up- 
set. 

The intervals between feedings should now be three hours, 
with one feeding omitted at night. The first formula 1 
should be 

Milk 2 ounces 

Milk-sugar 2 level tablespoonfuls 

Boiled water 18 ounces 

1 All formulae in this section are made up to 20 ounces. This method has been 
adopted because it is simpler and more widely understood than the other methods. 
As soon as the total twenty-four-hour amount exceeds 20 ounces, one and a half 
times or double the formula is made up, depending upon the total amount of 
food required. 



ARTIFICIAL FEEDING 283 

Method of Preparing Formula. — To make up a formula of 
whole milk the following articles are needed: 

Bottles — As many as there are feedings in twenty-four 

hours. They should be graduated in ounces. 
Measure — The best is an enamelware vessel marked on 
the inside in ounces and large enough to hold the 
entire twenty-four-hour amount. A glass graduate 
may be used but they break easily, especially if they 
are boiled. 
A small enamelware funnel. A tablespoon. Non-ab- 
sorbent cotton. Milk. Lactose (milk sugar). Boiled 
water. 
The bottles, measure, spoon and funnel should have been 
washed and boiled. 

The bottle of milk is well mixed so that the cream is evenly 
distributed and the desired amount of milk poured into the 
graduate. The desired amount of sugar is measured (three 
level tablespoonfuls equal one ounce), dissolved in part of 
the boiled water and added to the milk. Then boiled water 
is added to the mixture to make up the desired amount. It 
is now mixed and poured into the bottles, the proper amount 
for one feeding into each bottle. Finally the bottles are 
stoppered with cotton and placed in the ice-box. 

Increasing Formula. — The amount of milk and sugar in 
the formula can usually be increased every second or third 
day until the infant is taking 7 ounces of milk in each 20 
ounces of food with two and one-half level tablespoonfuls of 
lactose added. After this the increase has to be slower. By 
the time the infant is two and a half months old he will 
usually be taking equal parts of milk and diluent with two 
and one-half tablespoonfuls of lactose added to each 20 
ounces of food. While this increase in strength is taking 
place the amount is also gradually increased. It is best to 
begin by offering the infant 1 or 2 ounces at each feeding. 
Thus after the second day he will receive seven feedings of 
2 ounces each, making 14 ounces in each twenty-four hours. 
As soon as he is not satisfied with 2 ounces he may have more. 
The best method is to increase each feeding l A ounce at a time. 
Such increases can usually be made about every five days 
until the infant is receiving 4 ounces at each feeding, making 
28 ounces in each twenty-four hours. Most infants will 
reach this point about the fifth or sixth week. After this 
the amount may be slowly increased, reaching 5 ounces 
about the end of the third month, when the night feeding 
is usually dropped. At this time the infant will be receiving 
six feedings of 5 ounces each, making 30 ounces in each 
twenty-four hours. 



284 ARTIFICIAL FEEDING 

The strength and amount of the food is still gradually 
increased so that by the fifth or sixth month the infant is 
taking 36 ounces of a mixture containing two-thirds milk and 
one-third diluent with 1 ounce of sugar added to the twenty- 
four-hour amount. It is well at this time to increase the 
intervals between feedings, so that the total twenty-four- 
hour amount is not lessened. Thus an infant who has been 
receiving six feedings of 6 ounces each, 1 every three hours, 
will receive five feedings of 7 ounces each, one every four 
hours. 

From the sixth to the twelfth month the strength and 
amount of the food are increased very slowly. Most infants 
are taking whole milk undiluted and with no additions when 
they are ten to twelve months old. Delicate infants and 
those who have had digestive upsets frequently cannot 
digest whole milk until they are fifteen months old. The 
amount of each feeding is increased about an ounce each 
month until the infant is taking 40 to 45 ounces of food in 
each twenty-four hours. Usually this point is reached at 
eight or nine months. After this the increase is in the form 
of other food, the total amount of formula given being 
gradually reduced as the proportion of milk is increased. 

Cereal. — Frequently some cereal, usually barley water, is 
added to the food from the start. It is best to omit the 
cereal for the first two or three months in most cases, as its 
addition complicates the formula and adds one more factor 
which has to be considered when the food disagrees. After 
the third month it should be added, as it seldom disagrees 
by this time and, furthermore, it increases the carbohydrate 
content of the food slightly. The cereal most frequenty 
used is barley, either as a flour or pearl barley. The desired 
amount of barley flour and a pinch of salt are brought to a 
boil in an amount of water slightly less than that used in 
the formula, and then simmered for three-quarters of an hour. 
It is then strained, partly cooled and added to the milk. 
After the fifth month a stronger cereal mixture is used. If 
pearl barley is used it has to be cooked much longer. In 
other respects its preparation is similar. 

If the infant is inclined to be constipated, oat water is pref- 
erable. There are several oat flours on the market. They 
are prepared exactly like barley flour. If oatmeal is used it 
should be cooked at least four hours. 

Some infants do better with imperial granum water pre- 
pared in the same way. It may be tried when barley and 
oatmeal cause colic or indigestion. A considerable portion 
of its carbohydrate content is in the form of dextrins. Many 



HIGHER FAT MIXTURES 285 

infants like its taste better than that of either oat or barley 
water. 

The table on page 286 gives the composition of a series of 
formulae such as have been described with the approxi- 
mate age at which they should be used. While this table 
will serve as a guide it cannot be followed absolutely, as 
some infants will take more food or stronger food at the re- 
spective ages than that given in the table, and others will not 
be able to keep up to the schedule. Each infant has to be 
fed according to his individual needs and any schedule can 
serve as an approximate guide only. 

Dr. F. H. Bartlett has devised a ready method of com- 
pounding a formula for older infants. The caloric require- 
ment of the infant is calculated by multiplying 45 (the re- 
quired calories per pound) by the weight of the infant in 
pounds. From this he subtracts 120 (the calories furnished 
by 1 ounce of sugar). The remainder he divides by 20 (the 
calories furnished by 1 ounce of whole milk). This gives 
the number of ounces of whole milk which the formula must 
contain. The only remaining factors to be decided are the 
amount of food for each twenty-four hours, and the number 
and amount of the feedings. 

Suppose the formula required is for a healthy infant weigh- 
ing 16 pounds. The calculation is as follows: 

16 x 45 = 720. 720 — 120 = 600. 600 — 20 = 30. 
Such an infant would take 40 ounces in twenty-four hours, 
divided into five feedings of 8 ounces each. So our formula 
would be 

Whole milk 30 ounces 

Milk-sugar 1 ounce 

Barley water 10 ounces 

40 ounces 

five feedings of 8 ounces each, one feeding every four hours. 

This method is easy to remember and is very satisfactory 
for infants after the third month. In the early months it 
allows more milk than most infants can take. 

Higher Fat Mixtures. — A good many healthy infants are 
able to take mixtures which contain more fat than the for- 
mulas given in the table on page 286. There are certain 
advantages in using such mixtures in some cases. They 
furnish the necessary number of calories with less milk than 
the whole milk formulae. Infants taking more fat are more 
easily satisfied and usually gain more rapidly. Further- 
more, the tendency to constipation is less marked with 
infants taking more fat. The chief disadvantage, is that they 



286 



ARTIFICIAL FEEDING 



. 1 












O 10 10 C 




m 










^O « M O 




1 


oo 




0) 


M IO 


ON 


IO • • • • 


10 


i— i 










rt-fOlOCOH 




I 














5- 














O IONO 




m O 


w 


1— I 


CO 


11 IO 


00 


O ^-N ONVO 


10 


a 












Th • • • • 














fOiOM h 


Tf 






X 








O IO O O 




i 


vO 


M 


Tf 


hi IO 


t^ 


IO 01 <O00 VO 


10 












CO • • • • 














COVO 01 M 


Ti- 














O O Ol O 




°I 


lO 


01 


LO 


m VO 


vO 


VO O ONMD vO 


to 


I-H 










CO • • • 


*-< 












COVO 01 hi 


Th 












X 


10 




a 


Tl- 


01 


MD 


M VO 


10 


IO00 t^ tj-vO 


10 












CO • • • • 


ON 












01 VO 01 1-1 


CO 


03 

'1 












O IONO 




fO 


01 


x^. 


HH vo 


10 


O VO tJ- 01 vO 


10 


HH 










CO • • • • 


r^ 












01 VO 01 m 


CO 






X 




■X 


X 


X O id O O 




^\ o 


01 


Ol 


CO 


r^ 


Th 


h "tO hOO 





rog 












CO . . . . 


r^. 












01 r^ 01 O 


CO 






X 




X 


X 


X O O Ol 




i 


1— 1 


0) 


ON 


t^ 


Tt- 


h MOO ONOO 


10 












CO ■ ■ • • 


CO 












01 VO >-i O 


CO 


£>. 




X- 








O io>o 




o 


Ol 





• ^ 


Tt- 


00 m t^ • 





O CJ 












01 • • • • 





t^T3 












01 VO M 


CO 


3* 




X 




" 




t^. 




o\ 


01 


M 


• r-«. 


tJ- 


00 00 <o 10 • 





o cs 












01 • • ■ • 


00 


^•o 












m^Oh 


Ol 


3& 




X 






X 


h\ O f^ O 




oo 


0) 


04 


• r^ 


CO 


Tj-vo O Tf • 





10 i2 












01 • •■ • • 


VO 


csX) 












HH VO HH 


01 


£>• 




X 








O 01 01 




r^ 


04 


to 


• w 


CO 


i-H tJ-oo oi • 





io <3 












Ol • • • • 


Tf 


1H T3 












H l^H 


01 


3* 




X 






X 


X0010 




vO 


oi 


r*T 


• t^ 


01 


KNVO O • 





cs cti 














Ol 


mT3 












HH IO HH 


01 






X 






X 


H\0 ION 




5 £ 


»o 


Ol 


10 


• »>. 


0) 


r^ O cooo • 











M 






HH IO O 




01 






X 








OOO 




x: >, 


Ti- 


0) 


MD 


• r^ 


Ol 


Tj-00 hh r>. • 





£.<2 














00 


1 T3 












d 10 d 
















O O 01 




.c >. 


ro 


01 


t>. 


• r^ 


01 


Tt-vO 10 • 





tt^ 












M 4-6 


Tj- 














10 




"2 5? 


01 


Ol 


'CO 


• r^ 


01 


Tf- rt-OQ CO • 










M 






O CO O 












Cfl 
















ojO 




tfl . . 








_^ "3 




'in. 2 1 ^ 

c: <u 3 E 


u, 3 • C d 




Ol 




0) 


r <u 

s s * 




?8£ 


^3 


3 O ±2 <u « 

Is " fc " 

ot| ^3 a c - 


M 

< 


c 
3 
3 


en 
a> 


c 

3 
3 


+-> c 


0) 

'C c 
3 




^ 


a3 ^ O 
-1 PQ 




^i a ^s-§ 




1 


«% %£$-« ° 

-1 fc c/5 Oh CTj U 



BEEF JUICE AND BROTH 287 

are much more apt to upset the infant's digestion and to 
lead to a fat intolerance. Such an intolerance when once 
established may persist for a long time, necessitating the use 
of little fat over this period. 

By using the upper half of the milk in a quart bottle 
milk containing 7 per cent, of fat may be obtained. Before 
removing the top milk the milk should stand in the bottle at 
least four hours. Then the top milk should be removed with 
a small dipper. It should not be poured off. After being 
removed it is mixed and the desired amount used to make up 
the formula just as with whole milk. 

It is seldom wise to use these top milk mixtures for very 
young infants, but after the third month a vigorous infant 
will usually thrive on them. A formula containing slightly 
less milk than the appropriate whole milk formula should be 
used. Each ounce of 7 per cent, milk in the formula fur- 
nishes 0.35 per cent, of fat, while each ounce of 4 per cent, 
milk furnishes only 0.2 per cent, of fat. By using these higher 
fat mixtures the sugar content of the food can be reduced 
without lessening the caloric value of the food. This is 
desirable when feeding an infant with sugar intolerance. 

Food Other than Milk. — Orange Juice.— Artificially fed in- 
fants do better if given food other than milk earlier than 
breast-fed infants. This is especially true of those who are 
fed on pasteurized or sterilized milk. By the fifth month 
some fruit juice should be added to the diet. Orange juice 
is most frequently used. At first one teaspoonful of the 
juice diluted with an equal quantity of water is given one hour 
before one of the bottle feedings; usually the second feeding 
in the morning. The amount is gradually increased so that 
four to six weeks later the infant is taking i}4 to 2 ounces of 
orange juice each day. It does not have to be diluted after 
the first few days. Many infants do not like orange juice at 
first, but they soon take it readily. Its laxative qualities 
must be borne in mind and the number and character of the 
stools considered before increasing the amount. Often slight 
constipation can be controlled in this way. 

Beef Juice and Broth. — At seven months beef juice and 
broth are given, usually just before the noon bottle. At 
first one teaspoonful of beef juice diluted with an equal 
amount of warm boiled water and salted to taste is used. 
The amount may be gradually increased so that by the end 
of six weeks the infant is taking 1 or iyi ounces of beef juice 
every other day. Broth, either lamb or chicken, can be 
given on the alternate days. At first only ^ or 1 ounce at 
a time, but later as much as 4 or 5 ounces, should be given. 



288 ARTIFICIAL FEEDING 

Beef Juice. — Beef juice is made by searing a piece of lean 
beef, usually what is called "top round," and then squeezing 
out the juice in a small meat press. The fat will rise to the 
surface and may be skimmed off after it has stood a few min- 
utes. A little salt is added and frequently an equal volume 
of warm boiled water. Boiling or the addition of too hot 
water coagulates the soluble proteins and therefore should 
be avoided. It should be freshly prepared. 

Cereals. — At eight months some cereal, besides that in 
the formula, should be added to the diet. Oatmeal is the one 
of choice in most cases, especially when the infant is consti- 
pated. It should be cooked in water at least four hours and 
then strained. Cream of wheat or farina may be used when 
there is a tendency to loose stools. They are prepared like 
oatmeal except that they do not need to be cooked more than 
two hours. At first a teaspoonful with a little of the formula 
poured over it is given at the time of the second bottle. The 
balance of the bottle is given immediately afterward. A few 
days later the same amount may be given with the 6 P. M. 
feeding. The amounts are gradually increased so that by 
the ninth month the infant is taking ^ on ounce of cereal 
(i or 2 tablespoonfuls) twice a day. 

Egg. — At nine or ten months egg is given. The egg should 
be soft-boiled (two minutes) or coddled. At first only a 
little (i teaspoonful) of the white should be given. The 
amount is gradually increased and after a few days part of 
the yolk as well as the white is given. Some infants that 
cannot take soft-boiled or coddled eggs will take very finely 
grated hard-boiled eggs. The latter should be boiled thirty 
minutes. A few infants cannot take eggs in any form. Soon 
after ingestion they vomit and frequently they develop an 
erythematous or urticarial eruption and fever. All egg 
should be withheld from these infants, until they are older 
when they may be immunized to egg as Schloss has sug- 
gested. 

Vegetables. — Vegetables may be given after the ninth 
month. The best vegetables to begin feeding are spinach, 
summer squash, asparagus, or celery. Later string beans, 
carrots and lettuce may be added. All should be thoroughly 
cooked and then strained through a fine wire sieve. The 
resulting vegetable will resemble apple sauce in consistency. 
Of this one teaspoonful is given with the broth and egg at 
noon. The amount of the bottle feeding at this time should 
be gradually lessened as the other food is increased. The 
amount of vegetable may be gradually increased, so that 
the infant will be taking about a tablespoonful by the eleventh 
month. 



ABNORMAL SYMPTOMS 280 

Rice and Potato. — By the tenth month rice or baked 
potato may be added to the noon feeding. The rice should 
be boiled at least four hours. The potato should be dry and 
mealy, never soggy. At first only a teaspoonful is given 
but this may be increased to one and one-half tablespoon- 
fuls by the eleventh month. If the rice is given on the same 
day with the broth, it may be added to the latter and on 
the alternate days the beef juice may be mixed with the po- 
tato. 

Bread. — Bread or hard crackers, such as the Huntley and 
Palmer breakfast biscuits, may be given by the ninth or 
tenth month. The bread should be at least a day old, cut 
into thin slices and then dried on top of the stove until it is 
crisp and brittle. At first a small piece may be given with 
the 2 p. M. feeding, and later with the 10 A. M. and 6 P. M. 
feedings also. 

In the above schedules solid food has been added earlier 
than has been customary. The tendency of late, however, 
has been to feed solid food much earlier than formerly and 
certainly the results seem to warrant the change. While 
many of the infants do not gain as rapidly as when they are 
fed larger amounts of milk, especially when top-milk mixtures 
are used, they develop earlier and their bones and muscles 
are better formed and stronger. Furthermore, the tendency 
to rickets is much less marked in such children. 

The daily diet at twelve months of an infant fed in this 
way would be as follows. 

6 A. M. 8 ounces of milk. 

9 A. M. i or 2 ounces of orange juice. 

io A. M. Cereal, i ounce (2 tablespoonfuls) ; 8 ounces of 
milk (part on cereal and balance in bottle) ; 
dry bread, 1 small piece. 

2 p. m. Beef juice, 1 or 2 ounces, or broth, 4 or 5 ounces, or 
egg; boiled rice or baked potato, 1 ounce (2 
level tablespoonfuls) ; green vegetable, l / 2 ounce 
(1 level tablespoonful). 

6 P. m. Cereal, 1 ounce (2 tablespoonfuls) ; dry bread, 1 
small piece; 8 ounces of milk. 

10 p. m. 8 ounces of milk. 

ABNORMAL SYMPTOMS. 

While the great majority of breast-fed infants go through 
the first year without any nutritional disturbance many arti- 
ficially fed infants have more or less trouble. In some cases 
the difficulty is easily rectified, in others it is more severe and 
19 



290 ARTIFICIAL FEEDING 

may lead rapidly to death, or as more frequently happens, 
to a long chronic illness. These differences are those of 
degree rather than of kind, as they all depend upon the ina- 
bility of the infant to digest one or more of the several in- 
gredients of the food in the strength or amount furnished. 
Formerly the protein of cow's milk, especially the casein, was 
considered the most frequent cause of these disturbances of 
digestion, but recent evidence places the responsibility more 
frequently upon either the fat or the sugar. The condition 
is complicated by the fact that an infant who develops an 
intolerance for fat is likely soon to develop an intolerance for 
sugar, and vice versa, unless the first difficulty is promptly 
corrected. In many cases a carefully taken history will 
reveal the error which is at the bottom of the trouble. If 
this is corrected at the beginning an immediate cure may be 
effected. Where the history reveals no such error and after 
the disturbance has persisted for some time the best method 
is to reduce markedly the strength of those ingredients that 
appear to be at fault. While the logical way to classify 
these cases is according to the particular food-stuff which 
causes the disturbance, the difficulties of following this scheme 
are so great that it has seemed wiser to discuss different 
symptoms and their treatment. 

Vomiting. — The occasional regurgitation of small amounts, 
one or two teaspoonfuls, is of little importance. Holding 
the infant erect for a few minutes after he has finished taking 
his bottle enables him to belch what air he has swallowed 
with the feeding, and so eliminates the usual cause of regurgi- 
tation. 

Large amounts are vomited when the feedings are. too 
large or the intervals between feedings too short. A normal 
infant should seldom be fed more frequently than every 
three hours and even longer intervals are more successful 
with infants that are inclined to vomit. 

Too high a content of fat in the food is a frequent cause of 
vomiting. In these cases it is necessary to reduce the fat 
content of the food considerably below that proper for an 
infant of corresponding age and development. This is ac- 
complished by using partly or wholly skimmed milk in making 
up the food. After the vomiting has ceased the amount of 
fat in the food is gradually increased, but it is usually neces- 
sary to keep the fat slightly lower than normal for several 
weeks. 

Maltose preparations are more apt to aggravate vomiting 
than either lactose or cane-sugar. As a rule lactose is the 
best sugar. 



ABNORMAL SYMPTOMS 291 

When the vomiting consists of large curds the addition to 
the formula of some alkali as sodium citrate (one grain for 
each ounce of milk is usually sufficient), or the use of a cereal 
water as diluent instead of plain boiled water will help to 
prevent the formation of large curds and lessen the vomiting. 

Gas. — All infants swallow more or less air while taking 
their feedings. In order that the infant may get rid of this 
it is well to hold him erect for a few minutes after the feeding 
is finished. 

Gas in the intestine is either air that has been passed on 
from the stomach or the result of fermentation. The first 
is prevented by the precedure mentioned above. The 
second is controlled by reducing the amounts of sugar and 
starch in the food or by changing to another kind of sugar. 

Colic.; — Colic is a symptom of indigestion. Not infre- 
quently even a slight increase in the strength of the food will 
cause colic. In mild cases dropping back to the previous 
formula will stop the colic. When the strength of the food 
is next increased a smaller addition should be made. In 
more severe cases the food should be diluted with an equal 
part of water, or even more, until the symptoms subside, and 
then gradually increased. Constipation is a frequent cause 
of colic. Its treatment is considered in a later section. 

Loose Stools. — Loose stools are the result of the infant's 
inability to digest one or more of the ingredients of the fnod. 
The sugar is the most frequent cause. From the previous 
history and an inspection of the stools a conclusion as to 
which is at fault can frequently be arrived at. The formula 
should be made up without sugar, except what is in the milk, 
for a few days. As soon as the consistency of the stools has 
improved a small amount of sugar may be added to the food 
and gradually increased. If lactose has been used previously 
it is well to substitute cane-sugar or one of the dry prepara- 
tions of maltose. 

At times the fat is the cause of the diarrhea. In these 
cases it should be reduced temporarily and gradually in- 
creased as the condition improves but the amount of fat in 
the food should be kept below the previous point for some 
time. 

Diarrhea. — All recent cases should have all food withheld 
for twelve to twenty-four hours. During this time boiled 
water or a thin cereal water should be given. The water 
may have a very little tea added and be sweetened with 
saccharine if the infant takes it better this way. At least 
as much fluid as the infant usually takes should be given 
each twenty-four hours. If the infant will not take suffi- 



292 ARTIFICIAL FEEDING 

cient fluid, enteroclysis or hypodermoclysis may be used. 
For the latter an 0.8 per cent, salt solution is used; 150 to 
200 c.c. may be given two or three times in each twenty- 
four hours. 

After twelve to twenty-four hours food should be given. 
In the less severe acute cases a formula made up of boiled 
skimmed milk without any additional sugar is frequently 
successful. The strength of the formula will depend on the 
age and condition of the infant. At first the amount of 
skimmed milk in the formula should not be more than one- 
third that of the milk in the previous formula. In the more 
severe cases better results are usually obtained by using 
buttermilk or protein milk. The buttermilk is diluted with 
water or cereal water and later may have fat and sugar 
added to it. It should not be boiled. 

Protein Milk. — Protein milk (Eiwess-Milch) is prepared as 
follows: One quart of whole milk is heated to 98 F. Two 
rennet tablets are dissolved in an ounce of cold water and 
mixed with the milk. The milk is now allowed to stand at 
room temperature until it has coagulated, which takes about 
twenty minutes. It is cut and allowed to drain through two 
thicknesses of gauze until the curd is very dry. The curd is 
then washed twice with cold boiled water. The dry curd is 
mashed in a mortar and then forced through a very fine 
wire sieve. This may have to be repeated several times. 
One pint of buttermilk is then gradually added to the curd. 
Finally sufficient boiled water is added to make one quart. 
The composition of protein milk made in this way is about 
as follows: fat, 3.25 per cent.; sugar, 1.8 per cent.; proteins, 
3.75 per cent.; salts, 0.65 per cent. Each ounce furnishes 
about 15 calories. Protein milk may be made from 2 per 
cent, milk when it will contain about 1.5 per cent. fat. For 
very young infants it may be diluted. That with the lower 
fat content is preferable for young infants. The advantages 
of protein milk are its low sugar content (1.8 per cent.) and 
its high protein content (3.5 per cent.). For this reason it 
cannot be used for long periods without the addition of some 
sugar. The best sugar to give in this condition is maltose. 
It should be begun as soon as the stools are semisolid, at 
first only one teaspoonful in each twenty-four hours' food. 
Another teaspoonful may be added every second or third 
day. 

It is seldom wise to keep these infants on protein milk for 
long periods. In changing them back to milk mixtures it is 
safer to begin with a formula containing less fat than the 
protein milk. Even then considerable difficulty is frequently 



ABNORMAL SYMPTOMS 293 

experienced. Some of these infants will take unsweetened 
condensed milk better than ordinary milk. The unsweet- 
ened condensed milk is about two and one-fifth times as 
strong as ordinary milk and has to be diluted accordingly. 
Sugar has to be added to it as to ordinary milk. 

Constipation. — Constipation may be due to a too high 
fat content of the food, in which case the stools are large, dry 
and crumbly. Reducing the fat and increasing the carbo- 
hydrate, especially the starch content of the food, rectifies 
the condition. On the other hand, a food which contains 
too little fat will cause constipation. In this case the stools 
are not so large and more normal in consistency. If the 
infant is strong and healthy a moderate increase in the fat 
will frequently relieve the condition. 

One or two ounces of orange juice daily will help. Lime 
water should be omitted from the food and milk of magnesia 
used if an alkali is necessary. Furthermore, lactose and mal- 
tose are more laxative than cane-sugar and oat flour is more 
laxative than barley flour. 



CHAPTER XVIII. 

FEEDING OF THE PREMATURE INFANT. FEED- 
ING AFTER THE FIRST YEAR. FEEDING DUR- 
ING ACUTE ILLNESS AND IN NUTRITIONAL 
DISTURBANCES 

FEEDING OF THE PREMATURE INFANT. 

For the first twenty-four to thirty-six hours a premature 
infant should receive only small amounts of a 3 per cent, 
solution of lactose at regular intervals. One or two drams 
(teaspoonfuls) is given every hour to a three-pound infant, 
and a slightly larger or smaller amount to a larger or smaller 
infant. As these infants are at first unable to suck they 
have to be fed with a medicine dropper or with a Breck 
feeder. The latter is a glass tube with a perforated nipple 
on one end and an unperforated nipple on the other end. 
The tube is filled with food, the perforated nipple held in 
the infant's mouth and the other nipple gently squeezed. 
This method is useful for the larger, better developed in- 
fants, but is of no use for the very small infants. The latter 
have to be fed by gavage, and great care must be used in 
feeding them, as they are apt to regurgitate and aspirate 
part of the food, especially when it is given too rapidly or in 
too large quantities. 

The best food for a premature infant is diluted breast milk. 
As the mother's milk secretion is usually insufficient for the 
first two or three weeks the milk must be obtained from 
another woman. It is not essential that her infant should 
be of the same age. At the same time everything possible 
should be done to stimulate the mother's milk secretion. 
Her breasts may be massaged and pumped at regular inter- 
vals. A better method is to have the mother nurse a vigor- 
ous infant. 

Breast milk diluted with an equal amount of a 4 per cent, 
lactose solution is given after twenty-four to thirty-six hours. 
For very small infants the breast milk should be diluted with 
two parts of lactose solution. At first only two drams are 
given every hour. The amount is gradually increased to a 
half-ounce every hour, then an ounce every one and a half 
or two hours. At the same time the strength of the food is 
gradually increased. By the end of the second or third 
week the infant will be fed every two hours — 12 times in 

294 



FEEDING DURING SECOND YEAR 295 

each twenty-four hours, the total amount of food for twenty- 
four hours being about 12 ounces. By this time the breast 
milk should be little, if any, diluted. 

As soon as the infant is able to suck, it should be given the 
breast for a few minutes, but if insufficient food is obtained 
from the breast the necessary amount should be given after- 
ward. When the infant obtains sufficient from the breast 
the other feedings may be stopped. 

When it is impossible to obtain woman's milk, cow's milk 
mixtures must be used. At first 1 ounce of milk and 19 
ounces of a 4 per cent, lactose solution may be given. For 
very small infants the milk had best be partly skimmed at 
first. The amounts and intervals are the same as when 
breast milk is used, but the strength of the food has to be 
increased much more slowly. 

In feeding a premature infant it is important to remember 
that the food requirement is probably considerably less than 
that of a normal infant. 

FEEDING DURING THE SECOND YEAR. 

From the eleventh to the fifteenth month the schedule 
remains practically the same except that the 10 p. m. bottle 
can be stopped during the thirteenth or fourteenth month. 
It is often difficult to do this suddenly, but if water is gradu- 
ally substituted for milk the change is scarcely noticed. A 
good method is to pour off 1 ounce of the milk and add 1 
ounce of water, the next night pour off 2 ounces of milk and 
add 2 ounces of water. After eight or nine days the entire 
feeding will consist of water. The amount of water may now 
be gradually reduced. 

At fifteen months the 6 A. .M. bottle may be stopped and the 
breakfast given at 7:30 A. M., a small milk feeding being 
given just before the nap about 10:30 A. M. The orange 
juice may be given on waking or with the breakfast. At the 
same time the amounts of the different articles are slightly 
increased, and a greater variety of vegetables allowed. The 
daily schedule will now be as follows: 

6.30 a. M. Orange juice, 2 ounces (may be given with 
7.30 A. m. feeding). 

7.30 A. M. Cereal, 1 or 1 jounces (2 or 3 tablespoonfuls) ; 
dry bread, 1 small slice; milk, 8 or 9 ounces. 

10.30 A. M. Milk, 7 or 8 ounces. 

2.00 p. M. Beef juice, 2 ounces, or broth, 5 ounces; egg; 
boiled rice or baked potato, Y ounce (1 table- 
spoonful) ; green vegetables, Yi ounce- (1 table- 



296 FEEDING AFTER SECOND YEAR 

spoonful) ; stewed fruit (prune pulp or apple 

sauce) K or I ounce (i or 2 tablespoonfuls) ; 

no milk. 
6.00 p. M. Cereal, ior 1^ ounces (2 or 3 tablespoonfuls) ; 

dry bread, 1 small slice; milk, 8 or 9 ounces. 
About the fifteenth or sixteenth month all bottle feedings 
can usually be stopped, all fluid being given from a cup. 
The 6 A. M. bottle is stopped when the schedule is changed. 
A little later the breakfast bottle can be stopped, then the 
supper bottle and finally the 10.30 A. M. bottle. It is easier 
to stop them one at a time, rather than all at the same time. 
The 10.30 A. M. milk feeding can be stopped at about the 
sixteenth or seventeenth month. Many women, who are 
busy, find it a great convenience to continue one or two 
bottles during the second year. As a rule the infants do 
better if all bottles are stopped by the eighteenth month. 

Meat is begun about the fifteenth month. At first only a 
half-teaspoonful with the 2 p. M. feeding. The amount is 
gradually increased so that by the eighteenth month about 
one-half ounce (1 tablespoonful) is being taken. It is well 
to alternate meat and egg at first, meat and broth being given 
every second day, and egg and beef juice on the alternate 
days. Later the egg may be given with breakfast and meat 
given every day at 2 p. m. 

As the amount of solid food is increased during the second 
year, the quantity of milk is gradually reduced. Infants 
fed in this way rarely take much over 20 ounces of milk a 
day after the eighteenth month. This is important, as they 
will sometimes refuse to take sufficient solid food as long as 
they are given large amounts of milk. This . is especially 
true when the milk is given in a bottle. 

FEEDING AFTER THE SECOND YEAR. 

By the end of the second year, a normal child should be 
taking only three meals a day, with at times a cup of milk in 
the middle of the forenoon, before the nap. Between meals 
only water should be given, but this may be given freely 
especially in hot weather. It may be cool but it should not 
be iced. About 20 ounces of milk should be taken each day 
equally divided between breakfast and supper. Up to the 
fourth or fifth year it should be warmed, but after that it 
may be given at room temperature. Dinner at 1.30 p. m. is 
the main meal and consists of 5 or 6 ounces of soup (broth 
or puree), or 2 or 3 ounces of beef juice, meat (lamb chop, 
steak, chicken, roast beef or lamb), potato (baked or mashed), 



FEEDING DURING ACUTE INFECTIONS 297 

or boiled rice, some green vegetable (asparagus tips, stewed 
celery, spinach, string beans, carrots, summer squash, or 
fresh peas), and some dessert — either cooked fruit (apple 
sauce, baked apple, stewed prunes, peaches or plums), or 
rice pudding, junket, custard, apple pudding, tapioca pud- 
ding or occasionally vanilla ice-cream, and one or two slices 
of bread and butter. No milk but only water should be 
given at dinner. Breakfast and supper are simple meals. 
Breakfast consists of some cooked cereal (oatmeal, Pettijohn, 
cream of wheat or farina), a soft egg (soft-boiled, poached or 
scrambled), bread and butter and 8 to 10 ounces of milk. 
If desirable some cooked fruit may be given at breakfast. 
Supper consists of cereal, bread or toast and butter, and 8 
to io ounces of milk. 

The daily schedule would be about as follows : 
7.30 to 8.00 A. m. Breakfast: 

Cooked fruit (1 or 2 tablespoonfuls), if 
desired; cereal (3 or 4 tablespoonfuls); 
soft egg; bread or toast and butter; 
milk, 8 to 10 ounces. 
1. 00 p. M. Dinner: 

Soup, 6 ounces, or beef juice, 2 or 3 ounces; 
meat (1 or 2 tablespoonfuls); baked 
potato or boiled rice, 2 or 3 tablespoon- 
fuls; green vegetable, 2 or 3 tablespoon- 
fuls; dessert or cooked fruit, 2 table- 
spoonfuls; water. 
5.30 p. m. Supper: 

Cereal, 3 tablespoonfuls; bread or toast 
and butter; milk, 8 to 10 ounces; oc- 
casionally a soft-boiled egg or cooked 
fruit. 

FEEDING DURING ACUTE INFECTIONS. 

In feeding infants and young children during acute infec- 
tious diseases the important facts to be borne in mind are: 
first the great need of water, second the impairment of diges- 
tion, and third the fact that fats are not digested as readily 
as carbohydrates and proteins. 

Infants. — The total amount of fluid ingested should be 
kept up to the amount usually taken. More may be allowed 
if desired. It should be given in small amounts at frequent 
intervals between feedings. The food should be weaker 
than during health. For short illnesses which last only a 
few days, simple dilutions of the previous food is usually 



298 FEEDING DURING ACUTE INFECTIONS 

sufficient. At first the previous formula may be diluted one- 
half with boiled water or some cereal water. As the infant's 
condition improves the strength of the food may be gradu- 
ally increased, but the full strength should not be reached 
until the temperature has been normal for two or three days. 
If the illness is of long duration the formula may be made up 
with partly skimmed milk and two-thirds or even all of the 
usual amount of sugar. In this way the fat may be reduced 
as much as desired while the protein and carbohydrate con- 
tent of the food is only slightly reduced. 

Regular intervals of feeding are just as important with ill 
infants as with well infants. They should seldom be fed 
oftener than every three hours. Water, however, may be 
given freely between the feedings. 

Gavage. — Infants that are extremely prostrated, delirious 
or comatose frequently will not take sufficient food. If the 
condition persists more than a few hours forcible feeding 
becomes necessary. Such infants may be fed by gavage. 

Children Over One Year. — Regular intervals of feedings 
are just as important as with infants. During the febrile 
stage they should be fed every three hours during the day 
and if ill for any length of time once during the night, making 
five or six feedings in each twenty-four hours. Water should 
be given freely between the feedings. It is important to 
keep the total twenty-four-hour amount of fluid well up to 
the usual intake or even above the same. A child of two 
years should take at least 30 ounces, and one of four or five 
years 40 ounces in each twenty-four hours. If plain boiled 
water is not well taken, an alkaline water, as Vichy or Seltzer, 
may be given. t)uring the febrile stage the diet may in- 
clude broth, thin gruel, milk (diluted with water, Vichy or 
lime water), and albumen water (which may be flavored with 
orange juice). The gruels and milk furnish the most nourish- 
ment. Later cereals and dried bread may be added, then 
soft-boiled eggs and potato, and finally vegetables and 
stewed fruits. 

Gavage. — Delirious and comatose children may have to 
be fed by gavage. This can be done almost as easily as 
with infants by wrapping the child in a sheet. The food 
given may be predigested if advisable. Gavages should not 
be repeated oftener than four times in each twenty-four hours. 

Long Illness. — In illness associated with prolonged fever 
as tuberculosis the same general rules for diet apply as with 
adult patients. 



PYLORIC STENOSIS 299 

PYLORIC STENOSIS. 

In mild cases of pyloric stenosis dietetic treatment may 
be tried for a short time. If, however, some improvement 
is not quickly shown the case should be treated surgically. 
The best food according to Holt 1 is breast milk with a low 
fat content. If necessary the breast milk may be skimmed. 
If breast milk cannot be obtained a low skimmed-milk for- 
mula should be tried. As the condition improves the 
amount of skimmed milk in the formula may be gradually 
increased until the formula is sufficiently strong for the infant's 
age except that the fat content is low. Then the fat may be 
slowly increased, but it should be kept lower than normal 
for several weeks or months. As a rule these infants do 
best on long intervals between feedings, usually four hours. 
The amount of each feeding should be small, at first not 
more than two ounces. Later it may be gradually increased 
to the proper amount for the infant's age. Small amounts 
of water should be given between the feedings. Holt says 
that occasionally a case does better on small amounts at 
frequent intervals, as one-half ounce every hour. This is 
especially true when breast milk is used. 

Morgan 2 has given the best detailed statement of the post- 
operative treatment of these cases. His work is based on 
50 cases treated at the Babies' Hospital where the present 
routine is as follows. 

"The patient is given, an hour after operation, provided 
the recovery from the anesthetic has been complete, 16 c.c. 
of water, and an hour later 12 c.c. of breast milk mixed with 
4 c.c. of water. It may be necessary at first to use a medi- 
cine dropper for the administration. The breast milk is 
repeated every three hours, eight feedings a day, and is alter- 
nated with water. Both are gradually increased so that 
twenty-four hours after operation 16 to 24 c.c. of undiluted 
breast milk is being given every three hours and a similar 
amount of water between feedings. At the end of forty- 
eight hours the child is usually taking 20 to 30 c.c, at the 
end of seventy-two hours 30 to 45 c.c. at a feeding. The 
administration of water by mouth during the first three or 
four days is of the greatest importance. The time required 
to increase the milk to meet the caloric requirements of the 
child has been on an average of five days; in small babies 
three days may be sufficient, and in the well nourished as 
much as eight to ten days." 

x Jour. Am. Med. Assn., 1914, lxii, 2014. 
2 Am. Jour. Dis. of Child., 1916, xi, 245. 



300 CYCLIC VOMITING 

Morgan emphasizes the importance of breast milk for these 
cases, at least for the first ten to twelve days after the opera- 
tion. If the mother has been nursing the infant before the 
operation every effort should be made to keep up her supply 
of milk. The best method is to have her nurse a strong, 
healthy infant until her own infant is able to nurse again. If 
this is impossible her breasts should be massaged and emp- 
tied by means of a breast pump several times each day. 
Downes 1 says that the infant may be given the breast forty- 
eight hours after operation. Morgan advises a longer 
delay of not more than seven days. If the mother is unable 
to nurse her infant a wet-nurse should be obtained when 
this is possible. When this cannot be done modified cow's 
milk may be gradually substituted for the breast milk, be- 
ginning on the twelfth day. At first the formula should be 
considerably weaker than that proper for the infant's age. 

CYCLIC VOMITING. 

The cause of periodic vomiting is probably some error in 
metabolism, but until the cause has been determined, the diet 
cannot be so regulated as to exclude it. The one factor 
common to all cases is a well-marked acetonuria. In some 
cases the acetonuria appears very early, if not before the 
actual vomiting, in others the acetonuria does not appear 
until later, when it may well be the result of starvation. 

The dietetic treatment can best be considered under two 
headings: first that during an attack, and second, that dur- 
ing an interval. During an attack no food should be given 
by mouth. Water should be given freely either by mouth, 
by rectum or by hypodermoclysis. Small amounts may be 
tried by mouth, but if this aggravates the vomiting, as it 
usually does, it shculd be stopped. The best way is to give 
colon irrigations of one or two quarts of water every six to 
eight hours. The water should run in slowly, great care being 
taken not to overdistend the colon. A good method is to 
use an inlet and an outlet tube, the outlet tube being slightly 
larger and introduced two or three inches higher than the 
inlet. The amount of water retained can be calculated by 
measuring the amount allowed to flow in and the amount 
returning. At least 30 ounces should be retained in twenty- 
four hours. If insufficient water is retained from the irri- 
gations, hypodermoclyses should be given. In mild attacks 
normal saline may be used, but in severe attacks the use of 

x Jour. Am. Med. Assn., 1914, lxii, 2019. 



CYCLIC VOMITING 301 

a 2 or 3 per cent, solution of sodium bicarbonate helps to 
counteract the acidosis. As the sterilization of solutions 
of sodium bicarbonate changes the latter into sodium car- 
bonate, which is very irritating, it is necessary to change 
the carbonate back to the bicarbonate before using the 
solution. This is best accomplished, according to Howland 
and Marriot, by passing a current of carbon dioxide under 
aseptic precautions through the cold sterilized solution, to 
which a few drops of a phenolphthalein solution have been 
added, until all the pink color disappears. 

Alkali should be given in all cases, best as sodium bicar- 
bonate. It may be added to the water ingested, to the irriga- 
tions, or to the hypodermoclysis fluid. The endeavor 
should be to keep the urine alkaline. 

In protracted cases rectal feeding may be advisable. Four 
to 6 ounces of peptonized skimmed milk with 2 or 3 drams 
of sugar (dextrose) may be given every eight hours. 

When the vomiting has ceased for twelve hours, water 
may be given by mouth, at first in small amounts, y 2 ounce 
every hour. If this is retained, a thin cereal gruel may be 
tried, beginning with a teaspoonful every half-hour and grad- 
ually increasing the amount. The kind of gruel used may 
be varied: arrowroot, cream of wheat and farina are all good. 
Later thick cereal and either Huntley and Palmer breakfast 
biscuits or dried bread may be added. Then broth, white of 
egg, fat free milk, strained vegetables and scraped meat. 
All fat should be withheld for some time. 

Between attacks the plan which has proved most success- 
ful in our hands has been to withhold all fats for long periods. 
The child is allowed the usual diet for his age, except that 
the milk is fat-free and no butter, olive oil or meat fat is 
allowed. 

Occasionally these patients show sensitization to some 
foreign protein. Such proteins should be excluded from 
their diet, or an effort made to immunize the patient by 
feeding him giadually increasing amounts of the offending 
protein, according to the method devised by Schloss. 1 

Sufficient alkali, usually in the form of sodium bicar- 
bonate, should be given to keep the urine barely alkaline. 

After several months have elapsed without an attack, 
small amounts of fat may be added to the diet, but such 
additions should be considered experimental and should be 
stopped at the first evidence of a return of the trouble. 

1 Am. Jour. Dis. of Child., 1912, iii, 341. 



302 FEEDING IN NUTRITIONAL DISTURBANCES 

FEEDING IN NUTRITIONAL DISTURBANCES. 

Rickets.— Rickets is an extremely common disease, re- 
garding the cause of which very little is known. The one 
known fact common to all cases of rickets is a very low cal- 
cium content of the body, but why this occurs is not known. 
The amount of calcium in the food appears to be of little 
importance, as all the ordinary cow's milk mixtures contain 
an abundance of calcium, much more than breast milk. 

Breast-fed infants develop rickets under two conditions: 
first, when they are kept on the breast exclusively much 
longer than usual; second, among the very poor, especially 
the Italians and negroes in the large cities of America. Much 
has been written about the poor surroundings of such infants, 
especially the lack of sunlight and fresh air. Of possibly 
greater importance would seem to be the diet of the mothers, 
who eat very little fresh meat, milk, green vegetables and 
fresh fruit. Is it not possible that such a restricted diet 
deprives the mother's milk of something necessary to the 
infant for his proper growth? 

Artificially fed infants are particularly apt to develop 
rickets when fed on the various proprietary foods, especially 
those that are made up without milk. A prolonged diges- 
tive disturbance in the first few months often precedes rickets 
in an infant that otherwise may be doing very well when the 
rickets develop. Finally many artificially fed infants develop 
rickets, usually of a mild type, in spite of having had proper 
cow's milk mixtures and without having experienced any 
digestive disturbance. 

These facts would suggest that even good cow's milk mix- 
tures are frequently insufficient in some particular. Further- 
more cases of rickets are self-limiting, and begin to recover 
about the time they receive a liberal mixed diet. Funk's 
suggestion that rickets is the result of a lack of certain acces- 
sory factors or vitamines in the diet, would seem to offer a 
possible explanation, but it needs more proof than has been 
brought forward. At least it gives us a rational theory on 
which to base our treatment, and fortunately this coincides 
with the results of the best empiricism. 

The best prevention of rickets is breast feeding, but the 
mother's health should be watched and she should receive a 
liberal mixed diet, containing a fair amount of fresh meat, 
eggs, milk, green vegetables and fruit. When rickets devel- 
ops very early good breast milk will probably do more to 
check its progress than any artificial feeding. 



FEEDING IN N UTRITIONA L DISTURB A NCES 303 

With artificially fed infants all proprietary foods, especially 
those that are to be used without milk, should be avoided. 
Raw cow's milk mixtures, when it is possible to obtain a 
safe raw milk, are the best substitutes for human milk. Con- 
densed milk should be avoided. When the milk supply is 
questionable it may be pasteurized, but it should not be boiled. 
If the infant's digestion is deranged he may be unable to 
take raw or pasteurized milk at first but he should be changed 
to them as soon as possible. 

Fortunately rickets rarely appears before the sixth month, 
and by that time the' infant can be fed fruit juice and beef 
juice and a little later, egg, potato and green vegetables. 
All these articles should be begun in small quantities and 
gradually increased as is explained in the section on feeding 
(p. 287), but they may be begun considerably earlier in a 
case of rickets than with a normal infant. 



PART IV. 

FEEDING IN DISEASE, 



INTRODUCTION. 

The intelligent use of foods in disease should become more 
and more a matter of interest, not only to the specialist but 
to the practioner as well, and the time is far past when the 
conscientious physician can afford to turn over the diet regu- 
lation to the nurse, prompted by the patient's appetite or 
lack of it. As time has gone on we have come to recognize 
the importance of an adequate diet for the sick and the 
dangers which unnecessarily accrue to the patient from an 
insufficient supply of proper nourishment. With the tables 
of food values so generally at hand, the correct proportion 
of food elements, as well as the total food value necessary 
in a given case, may at least aproximately be easily calcu- 
lated. When the illness is slight or of short duration it is 
of course not so essential to go into minute details, but at 
least a general supervision should be kept of what the patient 
takes, even if a good deal of latitude is allowed in the choice 
of particular foods and drink. 

A sick person is proverbially difficult to please and when it 
comes to a matter of providing suitable food in a form that 
will appeal to such a patient, the difficulties are often nearly 
insuperable. Some simple rules might well be formulated 
to express the requirements of food and feeding in sickness. 

1. Food should all be as daintily prepared and served as 
possible, as much of the pleasure in food, as well as its proper 
digestion, lies in its manner of presentation to the patient. 

2. Food should be hot or cold as the patient prefers, iced, 
if necessary, but almost never served lukewarm. 

3. The seasoning of food should be carefully done, using 
preferably only the simplest condiments in minimal amounts, 
salt, pepper, celery salt. 

4. It should be served at regular intervals as nearly as 
possible. 

5. Only the easily digestible parts of foods should be pre- 
sented to a patient, as tender meats, young vegetables, etc. 
Avoidance of all well-known indigestible foods. 

6. All food should be thoroughly chewed and insalivated. 

7. The teeth and mouth should be kept in the best possible 
condition by tooth brush, mouth washes and cleaning of the 
tongue. 

305 
20 



306 FEEDING IN DISEASE 

8. Unless there is some special contra-indication, as in 
peptic ulcer, water should be regularly and freely given to 
the patient and a pitcher of water kept by the bedside for 
them to help themselves from when they are able to do so. 

9. A feeding cup or feeding spoon should be used in giving 
food to patients flat in bed, or if too ill to use the cup, fluids 
may be sucked through a glass tube. 

10. The physician, giving due regard to the patient's 
preferances and appetite whenever possible, should be 
absolutely definite in his direction, preferably writing down 
intervals for feeding, definite quantities at each feeding, the 
foods to be used and whether they are to be given hot or 
cold. When the illness is apt to be prolonged and the 
patient's appetite no guide, feedings on a definite nitrogen 
and caloric basis should be prescribed in order to conserve 
the patient's strength and weight as much as possible. 

11. The services of a good nurse who is personally agree- 
able to the patient must be insisted upon, whenever the illness 
is prolonged and finances permit. Such a nurse will be tactful 
in the care of the sick-room and feeding utensils. 

In any discussion of foods for sick people cognizance 
must be taken not only of the individual kinds of foods, but 
also that of their general type and preparation. Thus for 
example we might well divide foods for patients into — 

1. A normal general diet, meaning the diet usual for nor- 
mal people and applicable to patients who are more or less' 
confined by incapacities other than illness, e. g., a broken 
leg, etc. 

2. Soft diet, meaning a diet which is either put through 
a colander or capable of having this done, excluding vege- 
tables and fruits. 

3. Fluid diet, meaning a diet confined to liquid foods of 
various sorts. 

4. Milk diet, either as whole milk, buttermilk, skimmed 
milk, modified milk, malted milk, cream and milk mixtures 
alone or with alkaline additions. 

5. Convalescent diet which usually refers to a diet rich 
in easily assimilable proteins of delicate texture, made es- 
pecially nourishing and appetizing by various food acces- 
sories, jellies, condiments, etc. 

6. Diets to meet special mechanical or chemical body 
needs. Of these one may designate — 

A. Diets which have in view the power to neutralize 
excessive gastric acidity, as in peptic ulcer, by offer- 
ing a large amount of non-stimulating albumin, 
which readily combines with the gastric juice, e. g., 
lactalbumin and egg albumin. 



INTRODUCTION 307 

B. Diets particularly rich in basic salts useful in con- 
ditions where the hydrogen ion concentration of the 
blood is increased, as in chronic nephritis, cyclic 
vomiting, and the later stages of diabetes mellitus. 
These are the so-called alkaline diets useful in any 
condition characterized by an acidosis. 

C. Diets especially poor in salts, e. g., sodium chloride 
and calcium. The former being of use in almost 
any type of edema, especially that due to salt 
water retention in nephritis. The latter of doubt- 
ful value in chronic arthritic conditions or for ex- 
perimental purposes where a low calcium diet is 
needed. 

D. Diets especially rich in certain other salts, e. g., iron 
in anemic conditions, calcium in tuberculosis, 
(although it is doubtful if any excess of calcium in 
the diet is retained). 

E. Diets, poor in purine bases of use in gout and chronic 
nephritis and possibly in cancer. 

F. Diets low in protein, useful in chronic nephritis 
where we wish to spare the renal tissues as much 
work as possible. Also in certain types of intestinal 
disease accompanied by putrefaction. 

G. Diets high in protein, useful in convalesence and in 
fevers to a limited extent, also in all conditions 
accompanied by a rapid destruction of body pro- 
tein, e. g. t cancer, pernicious anemia, hyperthy- 
roidism (non-stimulating proteins only). 

H. Diets rich in carbohydrates, for fattening purposes 

and in intestinal putrefaction. 
I. Diets poor in carbohydrates where they are badly 

metabolized, e. g., diabetes mellitus and obesity. 
J. Diets rich in fats for fattening purposes and where a 
prolonged muscular effort is needed. Also in con- 
stipation. 
K. Diets poor in fats in obesity, in acidosis in any of 
its manifestations. 
It can be seen from the foregoing incomplete classification 
of diets in general that a good deal can be done on a definite 
scientific basis to select a diet suitable for many different 
conditions of varied body chemistry, either in normal or 
diseased persons. 



CHAPTER IX. 

DISEASES OF THE CIRCULATORY ORGANS. 

Diet in relation to diseases of the heart and bloodvessels 
is many-sided in that it must of necessity vary according to 
the particular condition under consideration, thus, for ex- 
ample, in acute infections affecting the heart, the diet should 
be in accordance with the principles of diet in fever or acute 
infections. In myocarditis, coronary sclerosis or decom- 
pensation of the heart from any cause, diet may be of ex- 
treme importance by virtue of its possible adverse mechan- 
ical effects, giving rise to dangerous or even fatal symptoms 
by pressure on the heart from the bulk of the food or from 
fermentation of the wrong kind of food or undue distention 
from gastric atony. In arteriosclerosis food may act as a 
cause, in that overeating has a distinct etiological relation 
to this disease and by the increase in blood-pressure caused 
by certain foods and drink, either from quantity or quality, 
a cerebral hemorrhage may be precipitated. These specific 
effects must be noted in addition to the usual nutritive role 
of foods. 

FUNCTIONAL CARDIAC DISTURBANCES. 

Functional cardiac disturbances are frequently purely 
matters of dietary regulation. Here the disturbance takes 
the form of either a tachycardia or an arrhythmia, and 
analysis of the diet may show the patient to be an excessive 
tea or coffee user or else to have a marked idiosyncrasy for 
these drinks. Gastro-intestinal disturbances are frequently 
at fault, usually accompanied by fermentation or confined 
gas, giving rise to a cardiac reflex through the vagus, pro- 
ducing extra systoles. 

Sutherland 1 puts it well when he says "more patients 
come to a doctor complaining of heart trouble when the 
digestion is at fault, than do those whose hearts are actually 
diseased." 

DIET IN ORGANIC CARDIAC DISEASE. 

Organic cardiac lesions may be acute or chronic, compen- 
sated or decompensated to varying degrees, and require 
special dietary consideration based upon these facts. 

1 System of Diet and Dietetics. 
308 



DIET IN ORGANIC CARDIAC DISEASE 309 

In the acute infections (endocardial or pericardial) the 
requirements are much alike, and one tries to furnish the 
needed food requirements in such form that they will be 
easily assimilated and promote excx'etion. Milk mixtures 
modified in various strengths, as often given in typhoid 
fever, are useful and fulfill the essential necessities, or a soft 
diet restricted as to amount. 

In compensated chronic valvular or myocardial disease, 
individuals need food in the same proportion and amounts 
as do normal persons, provided they are in other respects 
noimal. It is often a fact, however, that these people have 
other concomitant conditions which must be taken into 
account such as chronic renal disease, with or without hyper- 
tension, obesity, arteriosclerosis, etc., any one of which 
complications must be the determining factor in prescribing 
a diet. In such cases the food must be ordered in obedience 
to the limitations set to the diet for these conditions. Over- 
feeding any case of chronic cardiac disease would be mani- 
festly a mistake, as the resulting increase in body weight 
might completely change compensation to decompensation. 
On the other hand, these cases must be fully nourished in 
order to obtain the best mechanical result from a diseased 
organ and special attention given to preventing indigestion. 

Cardiac Decompensation. — In conditions of decompen- 
sation whether due to valvular lesion or myocarditis, diet 
is of great importance as already pointed out, and many 
systems of diet have been arranged for such cases. In the 
uncomplicated cases of mild or only very moderately severe 
decompensation, much the same rules hold true as for the 
compensated hearts, stress being laid on the fact that indi- 
gestion in all its forms must be prevented, as an acute attack 
of indigestion may change the prognosis from a favorable 
one to a prompt exitus, particularly in large, full-blooded 
individuals. The moderate restriction of fluids to prevent 
overfilling of the vascular system must also be kept in mind, 
particularly at meals only small amounts of fluid should be 
allowed. When marked decompensation supervenes we are 
at once in the presence of complications. All the internal 
organs are congested functionate at a disadvantage and 
often imperfectly; there is usually more or less subcutaneous 
edema and often collections of fluid in one or other of the 
body cavities; hence the indication is imperative that we 
should do nothing to further handicap the patient. It is 
for this state of things that most of the so-called dietary 
cures for cardiac diseases have been devised, and among 
these there are some worthy of more detailed discussion. 



310 DISEASES OF THE CIRCULA TORY ORGANS 

The Karell Cure. — The Karell Cure 1 is perhaps the oldest 
of these, although as originally published by Karell it is 
rather indefinite as to details. The idea of this diet and its 
many modifications is the same, namely, to furnish only a 
fraction of the daily food requirements by giving small 
quantities of milk for a time, then gradually increasing by 
adding other articles of food, keeping the total fluid intake 
down to 800 c.c. (27 oz.). 

For the first five to seven days: 8, 12 A. M.; 4, 8 P. M.; 
milk 200 c.c. (7 oz.). No other fluids. 
Eighth Day: Milk as above. 
10 A. M. 1 soft-boiled egg. 
6 P. M. 2 pieces of dry toast. 
Ninth Day: Milk as above. 

10 A. M. i soft-boiled egg and 2 pieces of dry toast. 
6 P. M. 1 egg and 2 pieces of dry toast. 
Tenth Day: Milk as above. 

12 Noon. Chopped meat, rice boiled in milk, vege- 
tables. 
6 p. M. 1 soft-boiled egg. 
Eleventh and Twelfth Days: Same as tenth day. 
No salt is used throughout the diet. Salt-free toast and 
butter used. A small amount of cracked ice is allowed with 
the diet. All meats can often be advantageously omitted. 
He explains the good effect of the Karell cure on the 
following grounds : 

1. The limitation of fluids. 

2. The low salt content of the diet. 

3. The elimination of toxins. 

4. Antitoxic effect (against uremia). 

5. Mechanical (no distention). 

N. B. Potter tried the effect of the Karell cure diet modified 
in various ways, keeping the total quantity at about 800 
c. c. (27 oz.) for the twenty-four hours, and found that the 
results were almost, if not quite, as good as the original 
Karell diet, with the added advantage that it is less mono- 
tonous. 

Potter's Modifications of the Karell Diet. 2 









Calories. 


Protein. 


Fat. 


Carbohydates 


I. 


Skimmed milk 


800 c.c. 


303-0 


27.2 


2.4 


41.8 


2. 


Whole milk 


800 c.c. 


570.7 


26.4 


32.O 


40.0 


3- 


Whole milk 


700 c.c. 












30% cream 


100 c.c. 


806.9 


25-6 


58.O 


39 i 5 


4- 


No. 2+ Lactose 


oz. j (30 gm.) 


685.4 


26.4 


32.0 


68.0 



1 Karell Diet, modified as used at New York Hospital. 

2 Potter, New YorkMed. Jour., 1916, ciii, 450; Arch. Gen. de med., 1866, ii, 513. 



Calories. 


Protein. 


Fat. Carbohydates 


9I50 


26.4 


32.O I24.O 


588.7 


27.I 


32 • 1 43 


3 


624.9 


28.7 


32.4 49 


9 


92I.7 


25.6 


58.0 67 


5 


825.O 


26.4 


58.1 42 


8 


939-8 


26.4 


58.1 70 


8 


1205.6 


28.0 


58.4 133 


4 



DIET IN ORGANIC CARDIAC DISEASE 311 



5. No. 2+ Lactose oz. iij (90 gm.) 

6. No. 2+ Oatmeal oz. j (cooked) 

7. No. 2+ " oz. iij 

8. No. 3+ Lactose oz. j 

9. No. 3+ Oatmeal oz. j 

10. No. 8+ " oz. j 

11. No. 3+ " oz. iij 

Lactose oz. iij 

While on this diet the patients often lose their edema and 
compensation is restored, but the great disadvantage is, of 
course, that so little of real food value is given that the 
patients are insufficiently nourished and a considerable loss 
of body protein results — a thing in itself often disastrous 
when the patient is already undernourished. Its usefulness 
cannot be denied in certain cases, particularly of the sthenic 
type, but it must be used with caution, never forgetting that 
we are at the same time starving the patient and probablv 
at longest it should only be used for a few days. There are 
various forms of restricted fluid intake, particularly as urged 
by Oertel and again by von Noorden, the former instituting 
practically a thirst cure and the latter recommending "thirst 
days" comparable to the " green days" in his diabetic die- 
tary regimen. 

Strauss 1 recommends a moderate amount of protein, 72.8 
gm., and warns against the extreme reduction as seen in the 
Karell diet, except for a very short time. He also restricts, 
but only moderately, the fluid intake and advises against 
Kraus's routine of reducing the daily amount to 1500 c.c, 
then 1000 c.c. and later 800 c.c, which amounts to a thirst 
cure. These restrictions are all more advantageous when the 
decompensation is accompanied by high arterial tension, — 
obesity or both. Many cases of decompensation when ac- 
companied by general anasarca do well on one of the salt- 
poor diets as recommended in renal edema, great good often 
resulting from the limitation of the sodium chloride intake 
(see Salt-poor Diets) unless the decompensation is extreme 
and the general internal congestion excessive. This is often 
more generally and successfully used than the Karell diet, 
as the patients do not lose strength and muscle substance 
while on it. As one would naturally infer, its greatest use- 
fulness is seen when there are renal complications. 

Carter 2 published the results of Gaulston's sugar treat- 
ment for decompensation and a year later Dingle 3 also re- 
ported a case. Both were cases of marked and progressive 

1 Veroffent. d. balneol. Gesellsch. in Berlin, 1912, xxxiii, 2, 27-37. 

2 Brit. Med. Journal, 1911, No. 1401. 3 Ibid, 1912, i, 66. 



312 DISEASES OF THE CIRCULA TORY ORGANS 

decompensation in which all the usual forms of diet and drugs 
had been tried without result. In each the success was 
marked and under similiar conditions is certainly worth 
consideration. Carter recommends that the cane-sugar be 
given as follows : First week, 2 ounces daily. Second week, 
3 ounces daily. Third and fourth weeks, 4 ounces, then 
gradually reduce to 3, 2 and 1 ounce. His diet is as follows: 
Breakfast: Coffee, ham, tongue, boiled egg, two pieces 

thin toast. No fat of any kind. 
Luncheon; One piece dry toast, spring cabbage (?), 
broccoli or asparagus with boiled fish, boiled meat or 
boiled chicken (no fat or sauces). Rice boiled in a 
little milk or water, sugar being taken on the rice. 
No fruits or acid taken. A tumbler of hot water to be 
taken one hour before luncheon and dinner and noth- 
ing to drink at either meal. 
Afternoon Tea: Two pieces of dry bread with sugar on 

it and a little sugar in a cup of tea. 
Dinner: Much the same as luncheon, only a flaked 
cereal instead of rice on which to take the sugar. No 
fats, fruits or sauces. 
Physiologically this method of increasing the efficiency of 
the cardiac muscle seems reasonable, as the heart obtains 1 
at least one-third of its energy from carbohydrates. It is, 
however, difficult to produce any hyperglycemia by means 
of the oral exhibition of sugar, so Biidingen 2 has tried rectal 
and intravenous injections of an isotonic (5.4 per cent.) solu- 
tion of glucose, with surprisingly good results in some in- 
stances. It is at least a method that deserves further trial, 
although hypodermic use of the glucose solution would seem 
a much simpler method to employ. 

Mackenzie insists that the food for cardiac cases shall be 
appetizing, nutritious, of small bulk, easily digested and thor- 
oughly masticated, and it might be added that in all cases, 
particularly in decompensation, the evening meal should be 
especially light. 

Fatty Heart. — Fatty heart is usually a part of a general 
adiposis, the heart being surrounded by an overcoat of fat 
with strands of fat even dipping in between the muscle 
bands. This gives a heart which has to work at a mechanical 
disadvantage, often with the resulting symptoms of decom- 
pensation, e. g., dyspnea on exertion, edema and palpitation. 
In the dietary treatment of this, the first object to be 
sought is a general reduction in body fat, which is best ac- 

] Jour. Am. Med. Assn., 1914, p. 1895. 
2 Deutsch. Arch. f. klin. Med., 1914, cxiv, 534. 



DIET IN ORGANIC CARDIAC DISEASE 313 

complished by one of the reduction cures. In these cases 
the Karell diet is especially useful and gives great satisfac- 
tion. Other methods are in accordance with the diets as 
suggested for reduction. 

Combined with any dietary routine there must go hand in 
hand a definite plan for the strengthening of the heart muscle 
by physical exercises, passive and active, for without this 
the reduction diets will leave the patient thinner, but with 
an entirely inefficient heart muscle, so that the second state 
is as bad as the first. For this purpose a sojourn at Nau- 
heim is of great benefit if one can go abroad, or in this country 
much the same result can be obtained at home by artificial 
Nauheim baths and resistance exercises if given under ex- 
pert direction. This regimen may be obtained at many of 
the American bathing resorts, among which may be men- 
tioned Watkins Glen, The Chamberlain, Old Point Comfort, 
White Sulphur Springs, Battle Creek, etc. 

In many cases merely the resistance exercises strengthen 
the heart muscle satisfactorily and at the same time add to 
the general muscular improvement. 

Diet in Adolescent Heart and Cardiac Myasthenia following 
Infectious Disease. — This condition is seen not infrequently 
in young people who grow rapidly in a very short time, there 
being a disporportion between the circulatory organs and the 
more rapidly developing bones and muscles. The result is a 
heart which is not well up to the ordinary strain of daily 
life or slight increase in activities. 

A condition of real disease does not exist, but an asthenia 
affecting the heart, accompanied by palpitation, breathless- 
ness after exertion, or a feeling of weakness and lassitude. 
The dietary regulations designed to overcome this state are 
merely such as would meet the conditions of malnutrition 
following a prolonged disease, which has left the entire 
organism myasthenic, and include the giving of foods that 
are primarily nourishing, with the exclusion of all fancy 
dishes, salads and unnutritious foods. The food should be 
simply prepared, giving three meals a day with a small 
extra feeding between meals and at bedtime, if the appetite 
allows. Milk, cream and butter are valuable and a fair 
increase in protein should be insisted upon. With a regu- 
lation of the diet should be combined good hygiene and 
light exercise gradually increasing always keeping below the 
patient's capacity. The use of the Nauheim resistance 
exercises does much to strengthen these hearts. 

Senile Heart. — The senile heart has received considerable 
attention at the hands of various authors, notably Balfour, 



314 DISEASES OF THE CIRCULA TORY ORGANS 

who goes so far as to prescribe an absolute diet. It would 
seem, however, that the rules laid down for cardiac condi- 
tions in general would apply equally well to the senile heart, 
remembering that elderly people require actually less food 
than younger individuals, as their metabolism goes on at a 
so much lower rate. The necessity of a light evening meal 
should also be emphasized. 

DIET IN DISEASES OF THE BLOODVESSELS. 

Arteriosclerosis. — When we come to consider the ques- 
tion of diet in arteriosclerosis we find almost everybody has 
something to say, most of it based on individual clinical 
evidence (?) and much on speculation. As a matter oi fact 
little is known of the specific action of food-stuffs on the 
various organs and whether this or that article of food causes 
or favors arteriosclerosis must yet be worked out experiment- 
ally in the biochemical laboratories. 

There seems, however, very direct evidence that persistent 
overeating in general is responsible for many cases and as we 
know experimentally that artificially raising the blood-pres- 
sure apparently causes arteriosclerosis (adrenalin injections 
in rabbits), all foods which raise pressure presumably favor 
its production. Longcope 1 showed that in animals after 
having been sensitized by previous injection, repeated inocu- 
lations of protein produced in the organs changes analogous 
to those seen in general fibrosis, whether of vessels, heart, 
liver, kidney, etc. Broughton 2 also showed by experiments 
that repeated anaphylactic shocks caused lesions of a 
degenerative type in the smaller arteries most marked -in the 
liver (ioo per cent.; kidneys (66 per cent,): heart (66 per 
cent.) ; spleen (ioo per cent.) This fact may have great bearing 
on the production of arterial changes. Clinically Bishop 3 
arrived at much the same conclusion, considering arterios- 
sclerosis, chronic nephritis, cardiosclerosis, etc., to be caused 
by the pathological reaction between the animal cell and some 
particular protein ingested or derived from bacterial growth, 
to which the organism had been sensitized, analogous to 
anaphylaxis. To combat this he recommends a diet in 
which all animal protein but one is excluded; cheese is the 
one usually given first, then later adding other proteins one 
by one to see if any one causes symptoms. This he calls a 
"few protein" diet, and proteins are used qualitatively 

1 Trans. Int. Med. Cong., London, 1913. 
2 Tv. Chi. Path Soc, 1916-17, x, 156. 
3 Med. Record, 19 13, lxxxiv, 511, 



DIET IN DISEASES OF THE BLOOD VESSELS 315 

rather than quantitatively. Whether or not this is a correct 
assumption, it is at least in accord with what little scientific 
data we have and is certainly worth careful consideration. 

Von Noorden 1 insists that there is no reason for leaving 
meat entirely out of the diet in arteriosclerosis, as we have 
proved nothing against meat as favoring its production. On 
the other hand, presumably anything which favors hyperten- 
sion favors arteriosclerosis and meat certainly, clinically, 
does increase blood-pressure when a large constituent of the 
diet. He does lay great stress on restriction of fermentable 
foods, heavy meals and more than a total of i}4 pints of 
fluid in the twenty-four hours, which alone he says often 
reduces the pressure 20 to 40 mm. Hg. (See Relation of 
Obesity and Reduction Cures to Hypertension.) 

Diet in Hypertension. — That which applies to arterio- 
sclerosis applies to hypertensive cases with apparently equal 
force, therefore it would seem wise to limit the amount of 
protein intake to the low level compatible with nitrogenous 
equilibrium, especially the purine bodies, as well as the limi- 
tation of quantity, calorically, to meet the needs of the 
patient as gauged by his various activities. The prevention of 
indicanurea is apparently of distinct advantage. Eustis 2 
observed that all (?) cases of high arterial tension were ac- 
companied by indicanurea, relief of which, by giving a non- 
nitrogenous diet, was often prompt. The explanation of 
this is based on Bargers 3 finding parahydroxyphenylethyl- 
amine (a pressor substance) in the blood of such patients. 
This, with Dale and Dixon, he also isolated from the tyrosin 
of putrefactive meat, another similar substance was produced 
from leucin from putrid meat. 

Cornwall's 4 rules for diet in hypertension probably repre- 
sent the consensus of medical opinion and might be formu- 
lated somewhat as follows: 

1. Keep the diet low in protein, 60 to 65 gm. per day, 
largely purine-free or with low percentage of extractives 
(soups and meat). 

2. Regulate the quantity to secure the minimum of work 
from the organs with maximum nutrition. The caloric 
value of which should vary from 1500 to 2000 to 3000 accord- 
ingly, as a patient is in bed, leading a sedentary life or work- 
ing. 

3. Restrict the diet so as to meet indications presented by 
the kidneys, liver, heart and gastro-intestinal tract. 

^ost Graduate, 1913, xxviii, 426. 
2 Southern Med. Jour., 1912, v, 244. 

3 Trans. Eng. Chem. Soc., 1909, xcv. 

4 New York Med. Jour., 1912, xcvi, 315. 



316 DISEASES OF THE CIRCULA TORY ORGANS 

4. The diet should be antiputrefactive, excluding fermen- 
table carbohydrates and should be laxative as well. 

The Effect of Various Substances on Blood-pressure. — 

1 . Food substances causing an increase of blood-pressure are 
principally the purine bodies in meat or meat soups, i. e., the 
extractives, for the lower the percentage of the latter in 
meats the less prone are they to increase blood-pressure. 
For this reason glandular organs are usually more likely to 
increase blood-pressure than other parts of the animal, and 
meat that is roasted or broiled has more effect than if boiled 
or, least of all, if boiled in two waters. Here too, food of 
almost any kind is much more apt to increase pressure if 
taken in large amounts, for, as already stated, overeating 
seems to be one of the chief factors in the production of 
arteriosclerosis and hypertension. Alcohol in moderate dos- 
age probably has little or no effect on blood-pressure — when 
taken more liberally it causes a fall in pressure. Excess of 
fluid in any form tends to increase pressure. 

2. Those foods which tend to decrease blood-pressure are 
the carbohydrate foods ; farinaceous foods, vegetables, fruits, 
fats, and milk preparations, as the latter are purine-free. 

Aneurysm. — Aneurysm has also been the subject of special 
dietary attention, Tufnell prescribing the best-known regi- 
men which is noted for its extreme restriction: Breakfast 
2 ounces of bread and butter, 2 ounces of milk or cocoa. 
Noon, 3 or 4 ounces meat with 2 or 3 ounces of potato or 
bread and 3 or 4 ounces of water. Night, 2 ounces of bread 
and butter, 2 ounces of milk or tea. Of course this is an 
absurd diet and only a strong person could stand it at all; 
the resulting blood concentration which it is hoped to gain 
is more than offset by the starvation necessary and would 
be distinctly bad for weak persons. All blood-pressure- 
raising foods should be avoided, however, as well as psychi- 
cal irritation, intestinal fermentation and bodily over- work. 1 

Angina Pectoris, — Both the rules for avoiding the produc- 
tion of arteriosclerosis and hypertension should be made use 
of, special attention being given to the avoidance of acute 
attacks of indigestion which often accompany a fatal attack 
of angina, although many times indigestion is undoubtedly 
secondary to the claudication rather than the cause of the 
anginal attacks. The evening meal should be simple and 
light. 

Tobacco in Relation to Cardiac Disease. — While not a 
food, tobacco is so generally in use that a word as to its place 

^echt Zwit. Fr. Med. Klin., 1912, lxxvi, 87. 



DIET IN DISEASES OF THE BLOOD VESSELS 317 

in cardiovascular cases is not amiss. Not much is really 
known about the continued effect of small doses of tobacco 
and its contained alkaloids, although there are many theories; 
there is, however, practical unanimity of opinion regarding 
its large or excessive use and that so used it is of distinct 
disadvantage. By its blood-pressure-raising qualities, its 
proneness to disturb digestion in some persons, to cause irri- 
tation of the myocardium (extra systoles) it is certainly best 
left alone in these conditions; whether a very moderate use 
of tobacco by its soothing and contenting effects may not 
offset the possible bad effect of continued small amounts is a 
question to be decided in each case. If a patient becomes 
susceptible to its effects or if used in large amounts, there is 
every reason for interdicting the use of this substance. 



CHAPTER XX. 
FEEDING IN DISEASES OF THE LUNGS. 

Much of what has been said in regard to the relation of 
diet to diseases of the circulatory apparatus holds equally 
true for the pulmonary diseases. In addition, food must be 
considered in its relation to acute or chronic infections, and 
from the mechanical stand-point as a possible factor in in- 
creasing symptoms by pressure from an overloaded or dis- 
tended stomach; besides, of course, its nutritional value. 

In pneumonia, lobar or lobular, we are dealing for the 
most part with a self-limited disease of short duration, i. e., 
as compared with typhoid for example. On this account the 
food quantities that are given would perhaps not be so im- 
portant if we could be sure a case would run for not more 
than seven to ten days. Unfortunately some of the cases 
run considerably longer or else develop serious complications, 
such as empyema, in which it is of the utmost importance 
that the patients should not have lost flesh and strength 
unnecessarily and so arrive at the late stages of the disease 
or its complications, in an overweakened condition. On 
this account the proper dietary treatment may have a very 
real bearing on the prognosis of the disease. 

The routine diet in these cases has usually been feeding of 
milk, broth, albumin water and gruels with a total nitro- 
genous content and caloric value far below the body's require- 
ments. Coleman, on the other hand, has applied the prin- 
ciples of the high caloric diet as used in typhoid and appar- 
ently with some success, but the need for the prevention 
of abdominal distension makes the giving of large quantities 
of food, especially carbohydrates, questionable, and as the 
majority of cases run but a week it is perhaps wisest to be 
content with nourishing patients, if not to the full limit of a 
theoretical capacity, at least sufficiently to prevent undue 
losses. 

The necessity for keeping the excretory organs unham- 
pered by excessive amounts of the products of food meta- 
bolism must also be kept in mind, for at times it seems as if 
we could ask little more than that the organs should remove 
the disease toxins as rapidly as they are formed. It is never- 
theless most important that sufficient food of the right sort 
should be given in order that the natural antitoxin-producing 

318 



PNEUMONIA 319 

organs should run at their highest efficiency, under the cir- 
cumstances, and as well, to prevent a starvation acidosis 
from further complicating the picture. We know, too, that 
in pneumonia the percentage of uric acid in the blood is 
always higher than normal, due to an excessive endogenous 
uric acid metabolism, and one should therefore avoid as 
much as possible feeding the purine bodies in the food. 
These two indications are met by giving a fair but not ex- 
cessive amount of carbohydrate and fats and a low purine or 
nearly purine-free diet, during the acute stage of the illness, 
all in a liquid or semisolid form. 

To adults accustomed to their cup of tea or coffee in the 
morning, this should be continued, but not in large amount, 
for Mosenthal has shown that the giving of caffeine to an 
already inflamed and overburdened kidney sometimes brings 
disaster. The broths and meat extracts and jellies are best 
left out of the dietary, as they contain only infinitesimal 
amounts of food and a high percentage of purine bodies. 
There is one legitimate use of meat extracts or broths in 
small amounts, namely, when anorexia is present a small 
cup of well-seasoned broth does more to cheer up a forlorn 
appetite than anything else. The diets No. I and No. 2 as 
outlined for typhoid fever represents a very good assort- 
ment of foods, leaving out the broth where indicated, also 
omitting some of the lactose if there is any indication of 
tympanites. A good diet for an average-sized person might 
be formulated somewhat as follows: 

8.00 A. M. Milk and coffee, each 120 c.c. (4 oz.), 240 c.c. 
(8 oz.) ; sugar. 
10.00 A. M. Milk in any form, hot or cold, 240 c.c. (8 oz.). 
12.00 M. Gruel, 120 c.c. (4 oz.), with milk 180 c.c. 

(6oz.). 
2.00 P. M. Milk feeding, as at 10.00 A. M M 240 c.c. (8 oz.). 
4.00 P. M. Gruel, 120 c.c. (4 oz.), with milk, 180 c.c. 

(6oz.). 
6.00 P. M. Custard with lactose (4 oz.) 1 cup. 
8.00 P. M. Milk feeding, as at 10.00 A. M., 240 c.c. 

(8 oz.). 
10.00 P. M. Whey, 180 c.c. (6 oz.), with one whole egg 

and sherry, 15 c.c. (}4 oz.) 
12.00 p. m. Gruel, as at 12.00 o'clock noon. 
2.00 A. M. Milk as at 10.00 A. m. 
4.00 A. m. Whey, 180 c.c. (6 oz.), or hot milk 240 c.c. 

(8 oz.). 
6.00 a, m. Milk, as at 10.00 A. M. 
Approximate values: Protein, 90; fat, 91; carbohydrate, 
220 gm.; calories, 1825. 



320 FEEDING IN DISEASES OF THE LUNGS 

The value of this diet can be considerably increased by 
adding 500 c.c. ( 1 pint) of cream if divided between each 
milk or gruel feeding, which would make the total values, 
protein 103, fat 180, carbohydrate 235, and calories 2800. 

Since sleep is of the utmost importance in pneumonia, a 
rest from feedings at night of from six to eight hours is advis- 
able if the patients will sleep, but they are to be fed when 
awake not oftener than every two hours. With the onset of 
tympanites feedings must be stopped for a few hours so that 
the beneficial effects of stupes to the abdomen and a hypo- 
dermic of pituitary extract, etc., may be obtained. When 
feedings are resumed it is often better to leave sugar and 
milk out of the diet unless the latter is fully peptonized (2 
hours) or else given in some other form than raw milk. The 
use of other artificial digestants is often of service. 

In this connection it seems worth calling attention to the 
use of a good Bulgarian bacillus culture given in a little 
sweetened water three times a day on an empty stomach. 
The apparent effect of this is often most happy in reducing 
the distention, as is also indicated in the discussion of typhoid 
fever. 

The feeding of cases of pneumonia complicated by neph- 
ritis will depend upon the severity of the latter disease but 
the aforementioned diet usually serves well, although it is 
often wise to have it prepared without salt. 

Drinks. — In addition to large amounts of plain water 
(provided the circulatory apparatus is in order), patients 
are usually grateful for fruit juices with water, such as 
lemonade, orangeade, grape juice, etc. When the ordinary 
foods are taken poorly a 5 per cent, solution of gelatin flavored 
with one of these juices makes it possible to supply, a good 
deal of nourishment, almost without the patients realizing 
that they are taking anything but flavored water. 

When the temperature falls and the symptoms of toxemia 
are past, a gradual return to a more normal diet may be 
begun, first by using soft diet, later adding meat and vege- 
tables as convalescence proceeds. A thorough emptying of 
the intestine by a cathartic, after the temperature is normal, 
is an invaluable aid to the digestion and helps the appetite 
to return. 

BRONCHITIS. 

Acute Bronchitis. — In adults, this is a condition sui 
generis, or a result of infection, possibly also due to sudden 
climatic changes, although this latter is presumably only 



BRONCHITIS 321 

predisposing. Then, too, there are the complicating cases 
of acute bronchitis occurring in the course of almost all the 
infectious diseases, such as pneumonia, typhoid fever, measles, 
etc. 

In certain elderly people acute bronchitis is a local manifes- 
tation of some general diathesis, e. g., gout and nephritis, 
and in these cases certain dietetic regulations referable to the 
underlying cause must be taken into consideration and the 
diet made to harmonize with it. Again in other cases it is 
a matter of general undernutrition and the bronchitis con- 
tinues to recur indefinitely until the organism is put in fight- 
ing trim by forced feeding and all measures to raise the phy- 
sical resistance, e. g., fresh air, exercise and general hygiene. 

When fever is present the diet should consist of liquid and 
soft solid foods, milk, cream, cereals, fruit juices, egg, creamed 
toast, bread, butter, coffee, cocoa, weak tea, mineral water 
and a large amount of any good drinking water. 

The appetite must be consulted and as this is often very 
poor, the patients for the first day or two frequently wish 
for nothing but cold liquids of one or another sort. If the 
intestinal canal has been thoroughly emptied at the outset, 
the appetite frequently improves, and it is then more easily 
possible to increase the food. Whenever possible it is always 
advisable to feed these patients up to the limit of their diges- 
tive capacity as it shortens convalescence and Coleman and 
Shaffer have found in their typhoid diet investigation that 
even a high degree of body temperature is not incompatible 
with liberal feeding, as the average patient is able to digest 
and metabolize food practically as well as in health, provided 
the proper foods are used. 

As soon as the patient wants solid food it may be given, 
omitting only the well-known indigestibles and much meat. 

Chronic Bronchitis. — Chronic bronchitis is frequently a 
condition accompanying chronic emphysema, and when so 
present is to be dieted in accordance with the suggestions 
detailed for that disease. In many cases it is the initial 
feature of asthma and as such is in need of an etiological 
diagnosis, when possible, in order to prescribe diet on any 
satisfactory basis. Thus we may find it a local expression 
of a general erythema, urticaria or anaphylactic reaction to 
foreign protein ; or a reaction to some form of endogenous 
toxicosis, gout or uremia; a complication of pulmonary 
tuberculosis or a reflex from some distant organ. Where 
any one of these causal condition are found, the diet appro- 
priate for the underlying condition must be made use of. 
If, however, none of these factors can be found as responsible 



322 FEEDING IN DISEASES OF THE LUNGS 

for the trouble, the only possible method is to proceed on 
empiric lines and frame the diet with a view to the least 
disturbance of digestion, both from the direct digestive 
point of view and the avoidance of mechanical factors which 
would work adversely in causing precordial pressure and em- 
barrassment of respiration. 

Foods to Avoid. — Keeping in mind both these possibilities, 
we must avoid ordering foods in themselves indigestible, or 
which are easily fermentable, such as members of the cabbage 
family; cauliflower, cabbage, Brussels sprouts, and heavy 
sweets. 

Foods Suitable in Chronic Bronchitis. — All simple foods, 
simply prepared, keeping down the amount of protein food, 
especially in elderly people; fat foods such as cream, butter, 
fat meat, etc., enjoy a favorable reputation in all chronic 
pulmonary affections and should be freely used. Laxative 
foods, such as fruits, green vegetables and simple salads, 
should form a considerable element in the diet, as excretion 
is to be promoted in every direction and a clear colon is of 
especial importance, for an acute exacerbation of the bron- 
chitis is often traced to an increase in constipation. Water 
drinking, up to six to eight glasses a day should be insisted 
on, either as plain water or in the presence of any consider- 
able degree of urinary acidity, partly as mineral alkaline 
water. 

EMPHYSEMA. 

Emphysema being for the most part a presenile change 
and usually accompanied by a general sclerosis of the other 
organs and bloodvessels, its dietetic treatment resolves 
itself principally into dietetics of the concomitant conditions, 
such as bronchitis, chronic nephritis and arteriosclerosis. 

The food should be simple, easily digestible and not apt to 
cause flatulence ; the sugars and starches should on the latter 
account be largely restricted. In fact any embarrassment 
of the circulation by abdominal distention may easily prove 
serious, particularly in the presence of marked arterial 
changes. There is no way of directly influencing the emphy- 
sema except by promoting the general health by means of 
careful attention to the details of eating, not alone in the 
character of the foods ingested, but the method of eating 
plays a considerable part in the care that can be given these 
people. 

In the first place great care should be taken not to overeat, 
not alone on account of the possible mechanical factors but 



ASTHMA 323 

because the waste products of digestion play such a part in 
the increase of symptoms due to the complicating conditions 
already enumerated. On the same account elimination 
should be promoted in every way and often the discomforts 
of digestive disturbances of all sorts are minimized by this 
means. It would seem as if Fletcher's principles of eating 
might afford great relief from the annoying complications, 
reducing as it does, the protein ration to the low level of 
physiological economy in nutrition and rendering the methods 
of forced elimination almost unnecessary, as there is the 
minimum of waste matter to be gotten rid of (see Fletcherism 
p. 649). Whether one follows this philosophy or not there is 
unquestionable virtue in keeping the intake of protein low 
and rendering combustion and elimination of food products 
as complete as possible. 

ASTHMA. 

As asthma is but a symptom of disturbance either primarily 
in the bronchial tree or remote in other organs, the first 
step in ordering a diet must be to determine what the under- 
lying pathological condition is. If it is due to a bronchitis, 
to a toxicosis as in nephritis or from gastro-intestinal disease, 
relief must be sought in the correction of the abnormal con- 
ditions including the diet suitable for each (q. v.). Formerly 
asthma was thought to be due to many nervous influences 
acting in a reflex manner, and while this may be true in a 
certain small proportion of the cases, it is by no means 
proved. A true explanation of many of the hitherto obscure 
cases is found in the phenomenon of anaphylaxis due to the 
effect of a foreign protein on an organism already sensitized 
to that protein. This is seen in hay fever very frequently 
and from dietary indiscretions where persons with a known 
idiosyncrasy to egg white, for example, develop an attack of 
asthma after eating some dish made with egg. Where the 
cause is known or easily found, the diet may be readily ad- 
justed. But there remains a large number of cases of asthma 
which cannot easily be etiologically classified — in these 
persons it is often helpful to test out the skin reaction to 
different proteins in the food, and where a protein is found 
to give a positive skin reaction it should be eliminated from 
the diet. After such a change in diet it is necessary to per- 
sist in it for at least ten to fourteen days, until all that parti- 
cular protein from previous ingestion is eliminated, before 
it is possible to decide whether the suspected protein is re- 
sponsible for the attacks of asthma or not. In certain indi- 



324 FEEDING IN DISEASES OF THE LUNGS 

viduals when the anaphylactic reaction is not too marked, 
it is often possible to overcome this condition by repeated 
feeding of small amounts of the food in question, gradually 
increasing the amount. 1 

When it is not possible by any method to come to a definite 
conclusion as to the cause of the asthma in a particular case, 
it is necessary to order diet on purely empirical lines, keeping 
in mind the following points: 

1. Indigestion, either gastric or intestinal, should be 
avoided by ordering only simple food simply prepared. 

2. The diet should be laxative as far as possible, as intes- 
tinal torpor in all its forms distinctly predisposes to the 
production of asthmatic attacks. 

3. It is probable that in many cases of unknown origin 
some one or other of the proteins is at fault, most often per- 
haps an animal protein. On this account it is often useful 
to curtail the amount of protein ingested, keeping the total 
daily intake down to the lower limits of physiological econ- 
omy in nutrition, as suggested by Chittenden. Another 
reason why this is often helpful is, that, in many of the older 
or long standing cases, renal excretion is deficient and with 
nitrogen retention, symptoms of toxemia often develop. 

4. Where the asthma is nocturnal, the evening meal should 
be exceedingly sparing and nothing allowed which by its 
bulk or from fermentation would add an element of embarrass- 
ment to the circulation in the lungs, by pressure upon the 
thoracic organs. 

5 Patients with asthma should take sufficient mild exer- 
cise to assist in the complete burning of the food-stuffs, 
leaving as little residue, either intestinal or systemic, as 
possible. 

6. Most of these patients are helped by drinking a fair 
amount of water, particularly between meals, and night and 
morning — six to eight glasses. With these suggestions in 
mind it should be a simple matter to order foods which meet 
the necessary conditions so far as it is possible to know them. 

Foods to Avoid. — Much sweet food, or heavy sweets of 
all kinds — syrups, candy, layer cake and preserves. Readily 
fermentable vegetables, such as cauliflower, cabbage, Brus- 
sels sprouts, much onion or potato. Alcohol, except in the 
most sparing amount and then only for some special indi- 
cation. Indigestible meats as: goose, duck, veal (unless 
very tender) and fresh pork. Tobacco should be used spar- 
ingly, if at all. 

1 Am. Jour. Elec. Rad., 1917, xxxv, 529. 



EMPYEMA 325 

What has been said in regard to diet in asthma holds 
equally true for cases of urticaria, which is usually, if not 
always, an anaphylactic skin reaction. 

PLEURISY WITH EFFUSION. HYDROTHORAX. 

In both of these conditions there is fluid in the pleural sac. 
In the case of a pleurisy it comes as a product of inflammation, 
in hydrothorax it is merely a transudation, principally from 
stasis, although even this is said by some authorities to be 
due to a low grade inflammation. 

In the early stages of pleurisy if -there is fever the patient 
must be fed as for any fever. When the exudate is estab- 
lished and the patients afebrile an attempt may be made to 
regulate the diet so as to assist in the removal of the fluid, 
for although not successful in the case of large exudates, 
small ones may be absorbed, often without recourse to tap- 
ping. To this end the two chief indications are to curtail 
the water intake to 800 to 1000 c.c. and exclude salt from 
the diet by the use of one of the salt-poor diets. (See Neph- 
ritis.) 

It must be remembered in employing these diets that fre- 
quently little result, so far as diminishing fluid or edema, 
occurs during the first few days, then, when the sodium chlor- 
ide reserve is considerably diminished, the free excretion of 
the fluids often begins. 

The dietetic treatment of hydrothorax depends more or 
less upon the underlying condition which is the cause of the 
fluid accumulation, e. g., nephritis and cardiac decompensa- 
tion. In either condition the same regimen as prescribed 
for pleuritic effusion is indicated, viz., limitation of fluids 
and a salt-poor diet, the details of either being dependent 
on the form of the nephritis or the degree of decompensation. 

EMPYEMA. 

Empyema whether due to invasion of the pleural sac by 
one of the ordinary pus organisms or whether the original 
infection is tuberculous with a secondary infection added, 
the dietetic indications are the same. The formation of pus, 
particularly in such great quantities as takes place in empy- 
ema, takes a large amount of fat from the body, as the per- 
centage of fat in pus is exceedingly high. On this account 
it is necessary to feed in large amounts as well as to prevent 
undue loss of body weight. If the fever is high it will be 
necessary to modify the usual diet in accordance with the 



326 FEEDING IN DISEASES OF THE LUNGS 

principles of fever requirements both in quantity and quality, 
but the fact must not be forgotten that if we are to hope for 
any success in our treatment the chief requisite is a body 
nourished up to the height of its capacity. 

To this end it is essential that a careful record be kept and 
the caloric value of the food estimated, for it is likely that if 
the patient's appetite is allowed to dictate the terms of the 
menu the total energy value of the food will be too low. If 
the appetite is poor, remember that milk either alone or 
modified upward by the addition of cream and lactose (see 
Typhoid Fever) can practically always be digested, even in the 
absence of appetite, provided too high a formula is not used. 
If the appetite is fair or good, then one must go ahead and 
feed liberally all digestible and nourishing foods, making 
sure that the proportion of fat in the diet is high by giving 
cream, 250 to 500 ex., ]/ 2 or 1 pint per day, butter up to 
250 gm. (yi pound), or as nearly that amount as will agree 
with the patient; for the rest the appetite may be trusted 
largely to determine the choice of foods. 

If the case is tuberculous in origin the diets as recommended 
for tuberculosis will be found useful. In either case great 
attention should be paid to the digestion to make sure that 
through light exercise or massage the muscular system is 
kept in condition. 

TUBERCULOSIS, PULMONARY OR GENERAL. 

In none of the infectious diseases is a proper dietary of so 
great importance as it is in tuberculosis; one has only to 
think of its older name ''consumption" to realize the truth 
of this statement; and whether the disease is seen in its acute 
or chronic form, pulmonary or other distribution, the neces- 
sity for a definite feeding plan is paramount. There can be 
no possible doubt that food, good food, properly chosen, 
properly prepared and eaten in cheerful surroundings is our 
sheet-anchor in this disease. So much has been written in 
all languages in regard to this, that it hardly seems necessary 
to dwell upon it, but apparently many practitioners either 
do not appreciate these facts or are too easy going to take 
them seriously and valuable time is lost, to say nothing of 
the patient's weight. 

Among the earliest symptoms of tuberculosis, the various 
disturbances of digestion rank a good second in importance, 
as many of the incipient cases first complain of gastrointes- 
tinal symptoms, such as gas, heaviness after meals and 
often sour stomach. Jacob 1 who examined the gastric con- 

x New York Med. Jour., 1913, xcvii, 297. 



TUBERCULOSIS, P ULMONARY OR GENERAL 327 

tents, after test meals, in 50 cases, found hyperacidity or 
normal acidity the rule in incipient cases, and that the symp- 
toms complained of were often similar to those of organic 
gastric lesions. He also concluded that the secretion of 
hydrochloric acid in fever was quite independent of the 
height of the temperature. 

By the older method of stuffing these patients with food, 
particularly in using large amounts of milk, the patients 
often developed the symptoms of gastric atony and many 
cases returned from sanotoria with a well-marked atony, 
due of course, to the very real weakness of the gastric muscle 
which was part of the general asthenia, but immensely ex- 
aggerated by overfeeding. Fortunately this mistake is now 
more rarely seen, particularly where any sort of intelligent 
care has been exercised in the selection of a diet. Toxemic 
dyspepsia in the tuberculous is also a cause for loss of weight 
or failure to gain. What then, should be the general prin- 
ciples upon which a suitable diet may be constructed? To 
this question one will find many answers. Some advocating 
high protein diets, others high fats and still others a diet 
high in both of these elements. 

First, the question of what should be the object sought in 
diet, may well be asked. There is now unanimity in the 
belief that a great gain in weight above the normal for the 
individual should not be soughr>and a weight of not over 
five to ten pounds overweight represents the optimum. Too 
much weight increases the work of the other organs and 
hampers the heart and lungs. When this has been gained 
Brown's 1 advice is certainly founded on experience and com- 
mon sense, when he advises patients to eat just enough to 
maintain this increase, avoiding milk. The little flare-ups 
and upsets in the course of the disease which cause loss of 
weight will come, and he then advises patients to take milk 
in addition to their regular diet until this weight is regained, 
then to drop it. (The use of milk will be further discussed 
later on.) 

The amount of protein proper for the tuberculous to eat 
has been the subject of much comment and discussion, one 
set of clinicians insisting that a considerable increase in this 
should be the rule, particularly as applied to animal protein, 
and Watson 2 estimates that this diet should be one-third 
more nutritive for the tuberculous than for the non-tuber- 
culous. This increase he applies to proteins and fats but 
not to carbohydrates on account of their tendency to fer- 

1 Canada Pract. Rev., 1912, xxxviii, 529. 

2 Practitioner, 1913, xc, 102. 



328 FEEDING IN DISEASES OF THE LUNGS 

ment. In recommending this increase in animal protein he 
refers to experiments proving that meat in uncooked form 
is especially beneficial, the effect being from the juices of 
the meat rather than the fiber, and that in some way the thy- 
roid is favorably influenced by uncooked meat, eggs and 
milk. He probably has in mind Cornil and Chautemesse's 
experiments in which they found that dogs fed on raw meat 
resisted artificial tuberculous infection better than those 
fed upon cooked meat. In advocating the meat diet 
(zomotherapy) in certain cases, Sutherland advises keeping 
up an exclusive meat diet as long as the patient continues to 
gain weight, weeks or even months. As they get better, 
heavier (having been underweight), the meat diet may be 
relaxed and varied menus given. If gastro-intestinal symp- 
toms develop the meat diet should be stopped, calomel or 
other cathartic given and the patient put on a milk diet 
3 to 4 pints (1500-2000 c.c.) daily, diluted with barley, 
lime or sodawater. After two or three days the meat diet 
may be resumed. 

Kendall, 1 on the other hand, is against an excessive pro- 
tein feeding on account of the extra work thrown on the 
kidneys in excretion, and quotes Bardswell and Chapman 
who thought that "patients made less satisfactory progress 
on diets of very large nutritive value than when smaller 
value and any considerable increase in the amount of pro- 
tein in the diet produced a disproportionate excretion of 
nitrogen, an increase in the amount of imperfectly oxidized 
proteins in the urine, a decrease in the percentage of nitro- 
gen absorbed and an increase in the amount of aromatic sul- 
phates excreted, indicating increased intestinal putrefaction. " 
Certain it is that we wish to keep the patient in at least full 
nitrogenous equilibrium, and while this can be worked out 
with scientific accuracy in a fully equipped sanitarium or 
hospital where nitrogen estimations can be made of intake 
and output, such a procedure is outside the range of possibility 
in ordinary practice. 

In planning the ideal diet for the tuberculous, one must 
take into consideration several factors. The question whether 
the patient has fever or not, whether it is necessary to con- 
tinue at work or whether freedom from care and work can be 
assured, for naturally the fever patient or one who is obliged 
to work needs more food than another, and individual judg- 
ment on the part of the physician must be used; but for 
the ordinary resting case, protein 80 to 100 gm., fats 80 to 

'Canada Med. Assn. Jour., 1912, p. 670. 



TUBERCULOSIS, PULMONARY OR GENERAL 329 

ioo gm,, carbohydrates 300 to 350 gm. would represent a 
good average, giving a total caloric value of 2500 to 3000 
calories. These, as in the case of other diets, can be worked 
out from the table of 100-calorie portions. Suitable diets 
for the tuberculous are so much a matter of money that 
although the patient with means can usually reach a good 
dietary under supervision — the poorer members of society 
often have an exceedingly hard time to secure even a main- 
tenance diet. A detailed study of some T. B. Dispensary 
families' diets for two weeks among Russian Jews, Poles, 
Italians and Negroes showed 1 

( 1 ) The average Dispensary family obtains about four-fifths 
the nourishment it should. 

(2) Ignorance of food values, poor judgment in buying 
were largely responsible, besides the poverty. 

To offset this condition Chadwick advocates a Caffeteria 
service for the Tuberculous poor as offering the most for the 
expenditure. 2 

Diets in Tuberculous. — As an example of the high protein 
diet we have the following published by Watson 3 which he 
especially recommends, No. 1 is largely a milk diet, No. 2, 
largely a meat diet. 

No. 1 

7.00 a.m. Milk, % pint (250 c.c). ' 

8.30 A.M. Milk, ]/ 2 pint (250 c.c) with casein ]/ 2 ounce 
(15 gm.), flavored with coffee or cocoa; 
gruel, made with milk and flavored with 
cream. 
11.00 a.m. Soup, thickened with yi pound (120 gm.) raw 
scraped beef; or soup thickened with an 

egg. 

1. 00 p.m. Chicken essence or veal jelly, strengthened 
with casein yi ounce (15 gm.) and milk yi 
pint (250 c.c) ; or raw meat minced Y± 
pound, with milk; or raw meat rissoles, 
with milk or raw meat sandwiches with 
milk. 

3 00 p.m. Milk with egg on thin custard. 

5.00 p.m. Milk tea, y 2 pint (250 c.c) with cream. 

7.00 p.m. Meat juice, e. g., Wyeth's Leube-Rosenthal's 
meat solutions mixed with port or Bur- 
gundy; or soup with raw meat, or beef ex- 

1 13th Rep. Phipps Inst. 1917. 

2 Mod. Hosp. 1917, 14, 403. 

3 Practitioner, 1913, 4C, 102. 



330 FEEDING IN DISEASES OF THE LUNGS 

tract with egg and milk forming a custard ; 
or milk and arrow root, with casein and 
cream, y 2 pint (250 c.c.); (brandy may be 
added). 
8.00 p.m. An invalid food made with milk, y 2 pint (250 
c.c), and casein. 
1 1. 00 p.m. Milk and egg or chicken broth and egg. 
In severe cases milk may be taken peptonized or fermented 
e. g., kumyss, zoolak; buttermilk or ripened milk (Bulgarian 
bacillus) may agree better. 

No. 2. A diet largely of meat, often helpful when dyspep- 
sia follows large meals. 

6.00 a.m. Milk, y 2 pint (250 c.c). 

8.00 a.m. Milk, yi pint, with casein y ounce (15 gm.), 
flavored with coffee, or cocoa and pepton- 
ized; slice of toast with butter; bacon, ham, 
eggs, fish, meat rissoles or steak (taking 
two things). 
1 1. 00 a.m. Glass of hot milk with eggs, or raw meat 
soup. 
1. 00 p.m. Luncheon — soup from strong stock, or fish 
soup or a helping of fish; mince, lightly 
grilled tender steak or chop, or slice of 
underdone sirloin of beef, or roasted leg of 
mutton; stewed fruit and custard or jelly 
with cream; toast, glass of milk. 
4.00 p.m. Cup of milk, tea, toast, butter, or biscuit and 

butter. 
7.00 p.m. Dinner — same as luncheon; a little wine. 
Prophylaxis for Children of Tuberculous Inheritance. — 
When one has to do with children of tuberculous parents or 
those who are more or less constantly exposed to this infec- 
tion, the necessity for a proper feeding plan is self-evident. 
Especial attention should be given to following the weight 
of the child from month to month so that the first sign of 
loss or even of failure to gain may be noted. The food should 
be especially nourishing and all other foods eliminated from 
the diet as much as possible. Particular hygienic care should 
be exercised in the daily routine and everything done in diet, 
work, play, sleep and fresh air to promote the greatest degree 
of physical efficiency. 

Plan of Feeding. — When a patient is able to take ordinary 
full diet the best plan is to give only three meals a day, pro- 
vided of course, the patient can eat sufficient at a meal to 
produce the required gain or to maintain an increase already 
accomplished. When a patient cannot attain this result on 



TUBERCULOSIS, PULMONARY OR GENERAL 331 

three meals alone, it is best to try between-meal lunches of 
reinforced milk, sandwiches, etc. Still other patients, of 
course, can eat only smaller amounts at a time and here the 
feedings must be more frequent, but if possible, three or four 
hours should elapse between them, using the two-hour inter- 
val only if necessary and taking care not to overcrowd a 
gastric muscle which may be already losing its tone. 

When the stomach is very irritable, any of the feedings 
referred to under gastric irritability may be used for this 
condition, or even gavage if necessary, as this often results 
in more food being retained than when given by mouth. 

Special Foods for the Tuberculous. — Milk. — Milk has 
from time immemorial, held the first place as an extra in the 
diet of these cases, but of late years a certain prejudice has 
arisen, particularly against its large use. The reasons for 
this have already been intimated in that it takes an exces- 
sive amount of milk, if one attempts to feed milk alone, 
which overdistends the stomach, often resulting "in atony, 
so that many clinicians have discarded its use entirely, while 
others use it for certain indications in very moderate amounts. 
The exclusion of milk from the dietary is no more sensible 
than its excessive use, but the indications for it may be per- 
fectly definite and it then is, of course, most useful, e. g., to 
add an extra to the diet in cases of failing nutrition; when 
people are especially fond of milk and in irritable conditions 
of the gastro-intestinal tract. In the latter, especially for 
cases with nausea, vomiting, diarrhea or fermentation; 
buttermilk or artificially ripened milk, kefhr, zoolak, etc., 
may be used to the greatest advantage. A very good way 
in these cases is to feed one of these prepared milks every 
two hours and with every other feeding to add some soft 
solid. 

Eggs. — Another form of food long popular in the treat- 
ment of tuberculosis, eggs still hold a prominent place in 
its dietary, but in the light of present-day physiological 
chemistry, eggs must be used as a very potent albuminous 
and fat food and enter into calculations of the diet as such, 
not to be taken indiscriminately in massive daily quantities 
in addition to regular meals, on the assumption that for the 
tuberculous patient the more food the better. Incidentally, 
slightly cooked eggs are better and more completely digested 
than raw eggs, since often only one third of the raw albumi- 
nous portion is digested at all, as shown by examination of 
the stools. 

Fats. — These hold a high place in the diet, for they are 
non-fermentable and their excretion does not tax the kidneys, 



332 FEEDING IN DISEASES OF THE LUNGS 

being oxidized into water and C0 2 . Animal fats being 
more nearly homologous are probably better than vegetable 
oils, and the fat from cod livers stands at the head of the 
list; for certainly this fat furnishes something which is in 
addition to its hydrocarbon content. Possibly it is its 
iodine and possibly something belonging to that little-under- 
stood class of food-stuffs called vitamines, but at all events 
clinically it does more for the patient than other fats do. To 
be sure, this can be taken only in limited quantities and the 
bulk of the fat in the diet must be made up of meat fat, 
butter, eggs and cream. The latter should always be taken 
fresh and not altered by pasteurization or sterilization. 
This applies to milk as well. 

The working standard for a diet in tuberculosis, according 
to King, 1 must take into consideration the following factors: 

"(a) Men of the same respective age and weight seem to 
require a larger diet than do women. 

"(b) All other conditions being equal, a larger diet is ap- 
parently required by persons under thirty years of age than 
is the case after that period. 

"(c) The laboring class, i. e., those who earn their living 
by muscular work, require more food than is the case with 
those living a more sedentary life, and in a certain measure 
the dietetic habits necessitated in the first place by occupa- 
tion persist after occupation distinctions are removed. 

"(d) The urban dweller consumes a larger relative amount 
of animal food and therefore derives a larger percentage of 
his energy from the protein constituent of his diet than is the 
case with the country dweller. This, of course, applies only 
to the higher orders of civilization." 

King then goes on to say, with these points in view and 
also keeping in mind individual variations, we may assume 
the following standards for ambulant cases of comparatively 
quiescent tuberculosis under sanitarium treatment: 

" (i) For young adult men of the 'working class' on very 
light exercise from 2800 to 3200 calories of which from no 
grams to 125 grams shall be protein. 

"(2) For the same class on five or six hours' vigorous exer- 
cise (sawing or chopping wood, working with shovels, pick- 
axes, barrows, etc.), from 3100 to 3600 calories of which 125 
grams to 140 grams shall be protein. 

"(3) For women of this class 200 calories and approxi- 
mately 10 grams protein may be deducted in each case. 

"(4) For young adult men, whose occupation has been 
more sedentary — e. g., clerks, bookkeepers, tailors, students, 

1 Med. Rec, 1909, October 16. 



TUBERCULOSIS, PULMONARY OR GENERAL 333 

etc., on moderate exercise (walking from one to three hours 
daily) — 2600 to 3000 calories, of which not over 115 grams 
need be protein. 

"(5) For women of this class not to exceed 2500 calories 
and 100 grams protein. 

"(6) For older patients, a slight reduction in caloric value 
and a considerably lower protein constituent are desirable 
in each case. 

" (7) For the country dweller a somewhat larger bulk, with- 
out increase in protein value is usually desirable, all other 
conditions being similar, than is the case with the patient 
from the city." 

King 1 then reports interesting experiences with diets in 
the Loomis Sanitarium. In 1905 the ration was about as 
follows: Protein 166 gm. (5^ oz.), fat 214 gm. (7 oz.), carbo- 
hydrate 323 gm. (103^2 oz.), calories 3955. While on this 
the patients seemed to thrive and gain, but digestive disturb- 
ances were common. The following year the standard diet 
was changed to protein 131 gm. {\Yz oz.), fat 113 gm, (3% 
oz.), carbohydrate 385 gm. (12% oz.), calories 3166. On 
this diet the gains in weight were equally satisfactory and 
there were very few digestive disturbances. It was also 
found that those patients who were able to work consumed 
more food and had a better digestion than those who did not 
or could not. The comparison of these diet values with 
those worked out by Bardswell and Chapman is as follows: 

Former Loomis Later Loomis 

Bardswell and Chapman. Annex standard. Annex standard. 

Protein . . 150 gm. Protein . . 166 gm. Protein . . 130 gm. 

Total calories 3200 Total calories 3667 Calories . . 3200 

While the caloric value of Bardswell and Chapman is the 
same as the later Loomis standard, King felt that the lower 
protein allowance was a distinct advantage on account of 
(a) economy, (b) increased efficiency, (c) better digestion. 
Complications. — In pregnancy, complicated by tubercu- 
losis, the diet should receive special care and on account of a 
tendency to decalcification, said by some to exist, 2 some form 
of lime should be freely supplied in milk and gelatin (the 
calcium content of milk and gelatin being comparatively 
high), or even as calcium lactate in regular daily amounts. 
This question of decalcification is still unsettled so far as 
the biochemists are concerned, but until it is positively de- 
termined it would be the wiser error to give calcium to these 

1 Diets in Tuberculosis. 

2 Dreman: Am. Jour. Obstet., 1913, lxxvii, 893. 



334 FEEDING IN DISEASES OF THE LUNGS 

cases in some form. The diet should also contain more pro- 
tein than at other times. 

Diabetes, from a diatetic point of view, is one of the most 
difficult complications of tuberculosis to treat. This is not 
an infrequent association and certainly taxes the ingenuity ot 
the physician to the utmost. The associated hypergly- 
cemia apparently favors the further development of the 
tubercle bacillus and yet a marked reduction in carbohy- 
drates is not always easy to obtain. The rules laid down for 
diabetes must be followed and an attempt made by increas- 
ing the proteins and fats to keep the body weight up to nor- 
mal and of course under these circumstances the kidneys 
cannot be spared, as they must be called on to excrete the 
excess nitrogen. 

General Rules for Feeding in Tuberculosis. — An epitom- 
ized statement for diet in tuberculosis might be put somewhat 
as follows: 

1. Forced feeding is not necessary. 

2. Milk and eggs are to be used strictly with respect to 
their food values 

3. A protein content of the food which furnishes a little in 
excess of ordinary requirements is best. 

4. Fats are especially useful. 

5. Three meals alone or three meals with three small 
lunches between and at bedtime offers the best distribution 
of meals. 

6. Avoidance of very bulky or fermentable foods should 
be insisted on. 

7. After normal weight or a weight slightly in excess of 
normal is reached, as little food should be taken as will 
maintain this weight. 

8. Food should be eaten slowly under the most agreeable 
circumstances possible. 



CHAPTER XXI. 
DIET IN DISEASES OF THE STOMACH 

The most important factor in the treatment of diseases of 
the digestive system is, of course, proper food, as this far out- 
weighs everything else; medicine and mechanical treatment 
taking an inferior position. The selection of a proper diet 
for these diseases depends upon a number of things which 
must be taken strictly into account if one wishes to obtain 
anything like satisfactory results. 

When the trouble is in the esophagus, one has to meet the 
conditions of stricture, dilatation or ulceration, either singly 
or combined. In gastric disturbances we have, speaking 
broadly, conditions of hyperacidity, hypoacidity, disturbed 
motility, narrowing at the pylorus, dilatation, and inflam- 
matory conditions ranging from the simplest catarrhal 
inflammation to severe ulceration or cancer. 

In the intestinal canal we must reckon with inflammatory 
conditions, narrowing, dilatation, disturbances of secretion 
or motility or any combination of these. Besides the ele- 
ments already enumerated there must be considered the 
integrity of the accessory digestive glands, such as the liver 
and pancreas. Hence it can be seen at a glance how many 
possibilities must be considered in choosing a rational diet 
for disease in any part of the gastro-intestinal tract. 

Among the most important factors that must be taken 
into account are the influences exerted upon gastric secre- 
tion by various agents. In general these may be classed as 
either excitants to gastric secretion or depressants. Among 
the former may be included, acids, spices, condiments, 
water, alcohol, rough foods, proteins with high percentage 
of extractives, concentrated sugar solutions. Among the 
depressants, fats (if they are bland) and alkalies are most 
important. Nervous influences, either reflex or psychic, 
act either as excitants or depressants to gastric secretion. 

In no other class of diseases is the personal factor so great 
as in digestive disturbances, for foods which may be per- 
fectly digested by a patient in health may not be in illness, 
so that one is constantly forced to vary the diet, not only 
for the different phases of these digestive troubles, but for 
each individual and the individual variations in each patient. 

There is how r ever, immense satisfaction in the careful diet- 
ing of gastro-intestinal cases, for in no other diseases is the 

335 



336 DIET IN DISEASES OF THE STOMACH 

proper diet more salutary than in these, save alone possibly 
some of the diseases of metabolism, notably diabetes. 

INDIGESTION. 

The proper digestion of food is such a complex matter 
that when one speaks of "indigestion" an endless variety of 
conditions naturally come to mind. Some of these are 
directly connected with the digestive processes and one may 
expect to get symptoms of so-called "indigestion" of an 
acute or chronic nature when any one of the digestive organs 
are involved in some form of derangement, and as well, the 
accessory digestive glands. On the other hand, one can 
have the most violent and persistent forms of indigestion 
referred to the stomach, whose origin is almost at the other 
end of the digestive tube; witness the effects on gastric 
digestion of a chronically diseased appendix, nephrolithiasis, 
cholelithiasis, adhesions, bands, etc., which may all result 
in digestive symptoms and which the patient refers to the 
stomach. It is in many ways unfortunate that the stomach 
seems to be the mirror for the whole abdominal cavity and 
almost everything that happens within the abdomen, parti- 
cularly when of a severe nature, has its gastric reflex, and 
the stomach, itself to blame for a sufficient amount of trouble 
has been obliged to carry the opprobrium for digestive 
troubles which have their origin elsewhere. Then, too, 
when one uses the word "indigestion" one thinks at once of 
the gastric and intestinal variety, so that it is necessary, so 
far as possible, to fix the blame where it belongs and use a 
term as broad as this with caution, properly hedged with a 
definite statement as to the organ at fault. Almost every 
form of pathological, anatomical or functional disturbance 
affecting the abdominal organs has its gastric or intestinal 
symptomatology. As an example of this one has only to 
mention any one of the chronic catarrhal conditions affecting 
stomach or intestine to bring to mind certain so-called symp- 
toms of indigestion and to this must be added various 
abnormal states of pancreas, liver, kidneys, etc., with gastro- 
intestinal symptoms in order to realize what a loose general- 
ization the term "indigestion" denotes. 

Given however, a normal gastro-intestinal canal and acces- 
sory glands there are certain conditions and substances 
which can produce symptoms which pass under this general 
name; various individuals differing in their reaction to 
different forms of irritation which may be mechanical, chemi- 
cal or thermal in origin. What suits one individual's diges- 



INDIGESTION 337 

tive apparatus may have an entirely different effect on an- 
other's and one has only to mention such substances as 
lobster, deviled crabs, hot breads, certain heavy sweets or 
fats with a high melting point in order to realize that some 
people cannot take these articles of food without a digestive 
upset, whether from anaphylactic action or a difference in 
digestive juices or motor function, while still others can take 
them with impunity. Foods, such as those undergoing putre- 
faction or fermentation, almost universally cause a more or 
less serious disturbance because very few possess the ability 
to detoxify these materials. Then, too, faulty mastication 
either from bad teeth, or lack of them, is very apt to result 
in disturbances which may be only functional, but are usually 
in the lon'g-standing or chronic cases due to actual pathologi- 
cal lesions of the gastro-intestinal tract. Rapid eating acts 
in the same way, also improperly prepared food, to say 
nothing of vegetable substances which are unripe. Ex- 
perience has shown that certain foods are always better 
borne when cooked than if eaten raw, and there is no doubt 
but that individual racial differences and habits cause the 
digestive apparatus to adjust itself to conditions which 
would spell "disaster" for people not accustomed to such a 
dietary. Could we eat the food of our ancestors of the stone 
age without disaster to our digestions? and the diet of 
our Eskimo brothers would, if eaten by us, cause many a 
troubled dream. Hence we see that the variety of differ- 
ences in different peoples and different individuals of the 
same people is infinite, not only in face and form, but in 
their reaction to different foods, and it is a wise man who 
early learns his own dietary impossibilities and has the 
strength of mind to avoid them. Still another factor enters 
into the question of the digestibility of foods, such as for 
example, the physic effect of anger, fear, etc., which inhibits 
the action of the secretory glands or causes motor irregular- 
ities of the stomach and intestine. Great stress is laid by 
Hayden 1 on treating cases of chronic indigestion by advanced 
suggestion (neuro-induction) after first finding out about 
physiological possiblities. Among the cases successfully 
treated are those who have been unable to take certain 
foods since childhood (excepting of course from anaphylaxis). 
These are often cured in one treatment. Again the effect of 
overwork, muscular or mental, is often to inhibit the diges- 
tive processes with the well-known sequelae of digestive 
disturbance ; and everyone knows that some foods which may 

1 Med. Press and Circl., 1918, n. s., cv, 146. 
22 



338 DIET IN DISEASES OF THE STOMACH 

be eaten at one time without difficulty prove a veritable 
source of sorrow when taken under other circumstances. 
One might go on indefinitely multiplying the factors which 
modify the digestibility of foodstuffs, but enough has been 
said to make the fact evident that there are individual 
differences in people, in foods, and in the circumstances under 
which they are eaten, that play an enormous role in the 
production of digestive unrest and result in what is gener- 
ally spoken of as " indigestion" in some one of its forms. 
One must, on the other hand, always seek for the underlying 
cause whether it be a condition of true pathology, functional 
derangement or individual idiosyncrasy, else one easily falls 
into the habit of thinking of "indigestion" as an indefinite, 
but comfortably large scrap-basket into which may be tossed 
a digestive symptom-complex, without taking the trouble 
to really get at its true significance. 

Diet in Irritable Stomach 1 (With Vomiting). — An irri- 
table stomach with nausea or vomiting is often a difficult 
problem in feeding. 

From whatever cause (after all that is possible has been 
done to find and remove it) it is usually best to give a stomach 
absolute rest. The length of time this is necessary will 
depend on many factors, but, generally a rest of from four 
to eight, twelve or twenty-four hours is enough, after which 
we may begin feeding somewhat on the following plan. 

Chloroform water (perfectly fresh) dram I (4 ex.). 
Peptonized milk (given five minutes later) oz. yi (15 c.c.). 
Repeat every hour, four doses. If there is no vomiting give 
chloroform water, dram 1 (4 c.c). Peptonized milk (given 
five minutes later) oz. 1 (30 c.c). Repeat every hour for 
four doses. If no vomiting advance to peptonized milk 
oz. 2 (60 c.c). 

GASTRIC HYPERACIDITY, HYPERCHLORHYDRIA. 

Acid dyspepsia is a very common diagnosis and it is prob- 
ably true that more than half of the patients who consult a 
physician for gastric troubles are found on examination to 
have a hyperacidity due to an excess of free HO. The 
time has gone by, however, when one can rest content with 
such a diagnosis, for hyperchlorhydria is in almost every, if 
not in every instance, merely a symptom and not a disease 
entity. One must therefore seek for the underlying cause 
which with care can almost always be successfully done. 
Kauff man's 2 classification covers the etiology satisfactorily and 
divides the cases into: 

1 Allen Whipple. 

2 Kauffman, in Forchheimer, iii, 75. 



GASTRIC HYPERACIDITY 339 

i. Those with an inborn disposition toward acidity. 

2. Due to faulty habits. 

3. Chronic intoxications. 

4. Reflex from disturbances in other organs (or in the 
stomach itself). 

1. Little is known about the first class except that one 
occasionally does find people who have always had a hyper- 
acid stomach extending from childhood, without evidence of 
a pathological basis. In these cases at the same time, must 
be borne in mind possible, but hidden, reflex causes, such as 
chronic appendicitis. 

2. Faulty habits account for a certain number of cases, of 
which may be mentioned, rapid eating, highly spiced foods, a 
great amount of acid food, or very sweet food and mental 
overwork. Students are very prone to have an exacerba- 
tion of hyperacidity during examination times, whether they 
have a real pathological lesion or not. 

3. Too free use of tobacco in any form accounts for cer- 
tain cases, and for some this means any use whatever of the 
weed. Some patients can smoke cigarettes or cigars in 
moderation without symptoms, while others have been known 
to precipitate an attack of hyperacidity by a few days of 
pipe smoking so regularly that the pipe has been given up. 

Alcohol, particularly when taken strong on an empty 
stomach, in the form of. cocktails or neat spirits frequently 
leads to a hyperacidity, and of course an actual catarrh 
later on if persisted in. Some patients cannot take coffee 
without increasing considerably the hyperacidity. 

4. The reflex conditions which may produce a hyper- 
acidity are legion and one has but to mention chronic appendi- 
citis, cholelithiasis, nephrolithiasis and peptic ulcer, to bring 
to mind numberless cases falling into this class. 

Given a case of hyperchlorhydria, if the cause can be 
found, of course treatment and diet must be directed along 
lines suitable for the particular condition at fault, but never- 
theless a certain number of cases remain which are evidently 
hyperacidity with the symptoms of pyrosis, eructations, 
often very acid, and some discomfort or burning in the epi- 
gastric region at the height of digestion. When there is 
actual pain, repeated daily, usually one to three hours after 
meals, there is almost always an organic lesion at fault, but 
if this can be reasonably ruled out, we must take dietetic 
measures to reduce the hyperacidity to a minimum. A 
diagnosis of hyperacidity can only be made satisfactorily 
by means of a test meal and, in fairness to the patient, this 
precaution should never be omitted. 



340 DIET IN DISEASES OF THE STOMACH 

The Reduction of Gastric Hyperacidity by Diet. — This is 
done first by the avoidance of certain foods which are sure 
to induce a certain amount of physiological increase in acidity 
and secondarily to give such foods as will render the excess 
of acid as innocuous as possible. To these ends one must 
avoid taking all acids, spices, condiments, salt meat or salt 
fish, and the use of salt on the food should be reduced to the 
minimum. It has been shown possible, in dogs, to feed 
meat boiled in distilled water until the salt intake is reduced 
almost to zero, when this is done the free hydrochloric acid 
production is actually controlled. This cannot be continued 
indefinitely in human beings, as sodium chloride in a certain 
minimal amount (i or 2 gm. per day) is necessary to health, 
but all excess can be obviated with some resulting diminu- 
tion in acid values in their gastric secretion. All foods must 
be avoided, which by their tough consistency would remain 
in the stomach a long time, such as very coarse vegetables, 
seeds, fruit skins or fats with a high melting-point, as mutton 
fat. Very hot or cold drinks or foods act in much the same 
way and must be left alone. Alcohol is especially bad in all 
forms. Meat soups are stimulating and are best omitted 
from the diet as are all hors d'oeuvre, such as caviare, olives 
and pickles, etc. Very sweet food has much the same effect, 
so all candy, rich cake, heavy preserves, sweet jellies must be 
left out of the diet. 

When one comes to construct a diet suitable for these 
cases one meets at once theoretical objections to many forms 
of food, and authority can be found for barring carbohy- 
drate or protein food, especially meats in all forms, for al- 
though they have a high combining power for the free HC1, 
they in turn are gastric excitants and would thereby defeat 
their own object. Diets based on this view are con- 
structed largely of carbohydrates and theoretically these 
should be well tolerated, but as a matter of fact for one 
reason or another they do not seem to act practically as we 
should expect, probably because although they call out a 
smaller acid secretion, they have little to offer to combine 
with the free HC1, which, once it accumulates in any quan- 
tity, causes the symptoms for which we are attempting to 
find the ideal diet. Fats do actually depress the acid secre- 
tions and when of a low melting-point, such as sweet butter, 
or when bland and liquid, as olive, peanut or cotton-seed oil, 
they are very valuable foods in hyperacid conditions for 
this quality, as well as for their high nutritive and caWic 
value. 



GASTRIC HYPERACIDITY 341 

But one cannot live on fats, so that to a certain extent a 
mixed diet must be used. Experience has shown that al- 
though milk is more or less a gastric stimulant, it offers such 
a high percentage of protein for binding the free HCI, that 
it is of great value, and a few days of a milk-and-cream diet 
is often most useful in quieting an overproductive gastric 
secretion. Eggs are good for the same reason although some 
authorities think that as the fat is in emulsion it is more 
stimulating than should be used; this is not, in the view of 
most clinicians, of sufficient weight to prevent their free use 
to advantage. The fine cereal preparations, such as farina, 
cream of wheat, malted breakfast food, wheatena, are all 
usable and are better than oatmeal. Bread is at times a 
marked gastric stimulant and Kauffman refers to hyper- 
chlorhydria in vegetarians for which he largely blames the 
excessive use of bread. Stale bread, toast, zweiback or 
crust of roll may be taken by these cases in moderation. 

Diet in Hyperacidity. — The diet in hyperacidity may be 
advantageously made up of the following articles, using con- 
siderable quantities of the less stimulating proteins: 

Raw oysters with a very little salt or a few drops of lemon 
juice. 

Soups: Cream or puree (except tomato) and made with- 
out meat stock. 

Fish: All white-meated, non-fatty fish, such as fresh cod, 
halibut, bass, white fish, boiled and served with egg sauce, or 
broiled (never fried). 

Meat: In marked hyperacidity meat is best let alone, ex- 
cept occasionally boiled or roasted and chicken or turkey. 
In less severe cases, minced lamb, without fat, guinea-hen, 
well-done beef without gristle, fat or gravy, in small amounts 
and never more than once a day, may be allowed. 

Vegetables: The soft green vegetables, such as young peas, 
string beans, spinach with egg, beet tops, celery, squash, 
vegetable marrow, rice, all boiled. Baked Hubbard squash, 
baked white potato, spaghetti. (No cabbage, Brussels sprouts, 
cauliflower or onions to be used on account of their tendency 
to ferment and cause flatulence.) 

Cheese: Cream, Neufchatel, Swiss. 

Desserts: All cream desserts, those made of egg and milk, 
such as custards, blanc mange, floating island, junket, soft 
rice, farina or bread puddings without rich sauces and best 
eaten with cream. Gelatin desserts if not highly flavored, 
all made with the minimum amount of sugar. 

Fruit: None at all in severe cases. In milder cases when 
constipation is marked, soft, subacid, stewed friuts may be 



342 DIET IN DISEASES OF THE STOMACH 

taken in fair amount, but no fruits with seeds or those with 
tough skins should be used, such as figs, raspberries, black- 
berries, gooseberries and prunes. Fruit should be stewed or 
baked with very little sugar. 

Bread: Toast, dry roll, zweiback, toasted crackers. 

Butter: Either fresh butter, or salted butter, if used, 
should be worked over in fresh water to take out as much 
of the salt as possible. 

Drinks: Weak tea, cocoa made with milk, cream, water, 
Vichy not too cold and never sparkling. 

Cereals: All fine well-boiled cereals. 

Eggs: In any form but fried or hard-boiled and not made 
into fancy entrees. 

Cake: A little cup cake, dry cookies and sponge cake. 

Foods to Avoid: All highly spiced, sour, salty foods, condi- 
ments, pickles, jellies, salted nuts, olives, raw vegetables as 
celery, salads, radishes, etc. Very cold or hot foods or 
drinks, or if taken in small amount they should be kept in 
the mouth long enough to bring their temperature to about 
body heat. Uncooked vegetables of all sorts and hard sub- 
stances as corn. Coffee, wines, beer, liquors, cordials, ale, 
ginger ale and cold soft drinks. Pies, syrups, pancakes, hot 
biscuits, cake other than those already mentioned. 

GASTRIC HYPERSECRETION. 

Since hypersecretion whether intermittent or continuous 
is a symptom of disease and not a disease itself, it is neces- 
sary, in order to prescribe a rational diet, to know if possible 
what the underlying cause may be. In the intermittent 
variety we may be dealing with merely a part of a general 
neurosis or it may be a gastric manifestation of a lesion of 
the central nervous system, such as tabes or lateral sclerosis, 
where it is regularly an accompanying feature of the gastric 
crisis. It may also follow the excessive ingestion of alcohol 
or gastric irritants or accompany acute gastric dilatation 
{a. v.). 

In the intermittent variety the diet should be arranged so 
far as possible in accord with the etiological factor. Since 
hypersecretion is practically always accompanied by a defi- 
nite hyperchlorhydria the diet should be chosen on the basis 
of the foods recommended for this condition. A few days 
or a week or more of a milk diet with or without the addition 
of very soft-boiled eggs, gives relief to most of the cases, 
regardless of the etiology, excepting only those cases due to 
a lesion of the central nervous system, as tabes. The relief 



GASTRIC HYPOACIDITY 343 

is, however, often only symptomatic and a test meal will 
still show hypersecretion and hyperacidity unless in case 
of ulcer there had been actual healing. 

Continuous Hypersecretion is for the most part a symptom 
of gastric or duodenal ulcer and unless this can in some way 
be excluded, as by x-ray examination, it is fair to assume 
such a relationship, particularly in the presence of ulcer 
symptoms, and institute an ulcer cure. 

The pain which so often accompanies hypersecretion may 
be ascribed probably to pylorospasm or possibly to an irri- 
tated ulcer and, while a milk diet will also bring relief to this 
symptom it will do so permanently only so far as the diet 
is successful in curing the underlying ulcer. 

While usually a high protein diet is advocated for hyper- 
secretion, it will be seen from what has been said that this is 
rather a shot in the dark and that if one wishes to use foods 
intelligently it is absolutely necessary to first make an etio- 
logical diagnosis. 

In general it may be said that the protein of milk and egg 
is the best for all cases of hypersecretion, whereas, meat or 
meat products are distinctly stimulating to gastric secretion 
and should be omitted from the diet at first, and later allowed 
only in small amount and in the more easily digested forms, 
e. g., chicken, mutton and sweetbreads. Soft farinaceous 
puddings and cereals are allowed in moderation and puree of 
vegetables, as in hyperchlorhydria (q.v.). Especial import- 
ance is attached to the avoidance of condiments, acid food 
and drink, rough foods, skins, seeds, corn, etc., all of which 
remain a long time in the stomach and produce thereby 
irritation, and in addition the thermal irritants, such as very 
hot or very cold foods, are to be avoided. 

GASTRIC HYPOACIDITY AND ACHYLIA GASTRICA. 

Diminution or absence of gastric acid and ferments, as its 
name implies, is the direct opposite of hyperchlorhydria and 
may be due to a variety of causes, either organic or func- 
tional. Of the organic causes any long-standing catarrh of 
the stomach will lead to it and it is found as a frequent com- 
plication of catarrhal gastritis and gastric carcinoma, per- 
nicious anemia, severe infectious diseases at times and in 
many elderly people. In any event permanent achylia is 
accompanied by atrophy of the mucous membrane of the 
stomach and its secreting glands. 

Of the functional causes, many cases are due to profound 
neurasthenic conditions and as a reflex from organic disease 



344 DIET IN DISEASES OF THE STOMACH 

in some of the other abdominal organs, e. g., chronic appen- 
dicitis or cholelithiasis. There is still another class of case 
in whom the achylia gives rise to no symptoms and is only 
found by accident in the course of a routine examination. 
The cause of this variety is far from clear. 

The degree of the hypoacidity varies within wide limits and 
runs from a slight reduction in the free HC1 and total acid 
values and without change in the pepsin-rennin secretion, 
all the way to complete achylia with total absence of acids 
and ferments. In passing, it might be remarked that the 
acids are diminished more frequently and in greater propor- 
tion than the ferments. In the cases in which the hypo- 
acidity is dependent on a definite lesion, as for example 
gastritis, the return of the acid is greatly dependent on the 
outcome of the underlying cause, which if cleared up may 
result in a return of the secretions. Other cases are found 
without definite cause as already stated and remain achlyia 
to the end of the chapter, apparently with little effect on the 
general health, 

The diet problem in hypoacidity is in many respects a 
much more simple matter than in most cases of marked 
hyperacidity and within certain limits the foods which are 
inadvisable in hyperchlorhydria on account of their tending 
to excite gastric secretion, are the ones which we may often 
freely use in this opposite condition. 

Mention has already been made of the diet best for these 
cases in connection with chronic gastritis with hypoacidity 
(p. 348), but it is necessary to go more into detail. Where 
there is a definite organic cause or accompanying condition 
to the hypoacidity or achylia the diet must be in accordance 
with this complicating feature and all foods which are in any 
way irritating must be avoided, such as condiments, strong 
acids, very rough or hard foods, skins, seeds, etc., as the 
mucous membrane in many of these cases is exceedingly vul- 
nerable and bleeds easily, even on the introduction of the 
stomach-tube. Very hot foods or large quantities of acid 
food or drinks must be avoided. 

Theoretically very limited protein should be given, as in 
the absence of the normal HC1 and pepsin, gastric digestion 
is at a minimum or entirely absent. Within certain limits 
this objection holds good, namely for all protein foods diffi- 
cult of digestion, e. g., veal, tough meats of all sorts, con- 
nective tissue (which latter is only digested in the presence 
of free HC1 and pepsin) and tough clams, lobster, etc. On 
the other hand, the patients must receive their full daily 
allowance of protein and will be able to digest the proper 



GASTRIC HYPOACIDITY 345 

kinds in the course of pancreatic and intestinal digestion. 
Of these, milk, eggs, tender meats and fowl cut very fine with- 
out gristle or connective tissue, mild cheeses, tender white- 
meated fish and vegetable protein of all sorts must form the 
bulk of the protein ration, but given preferably in only 
moderate amount say from 70 to 90 grams per diem, and not 
to the high limit allowable in a normal person. While a 
moderate amount of these protein foods can be entirely 
digested in the intestines, any excess will throw too much 
work on these accessory digestive processes which may easily 
go out of commission on this account, with the result that 
the proteins in excess undergo putrefaction in the intestine, 
giving rise to many uncomfortable symptoms of toxemia. 
This is the more prone to happen as the normal gastric juice 
is a strong antiseptic for all foods brought to the stomach 
and it is a hardy germ that can live through the acid immer- 
sion it receives there. On this account the normal chyme 
is comparatively free from bacteria; a fortunate provision of 
nature when one considers the quantity of poor gastric 
surgery that is done, much of which would be followed by 
greater disaster were it not for this fact. 

Since the natural barrier to the entrance of pathological 
bacteria is largely or entirely missing in these cases of hypo- 
acidity, it is of the greatest importance that the food taken be 
all thoroughly cooked to render it sterile. Fruit with skins may 
be an exception to this rule, as they are really practically 
sterile within their skins. For the same reason great care 
should be taken of the mouth and its toilet made before and 
after meals, using toothpick, dental floss, tooth brush and a 
good mouth wash. This seems excessive care, but many 
cases of diarrhea and chronic intestinal infection are started 
by reason of carelessness in these respects. 

Clear soups are good for their appetizing and stimulating 
effects on the gastric glands that are still capable of stimu- 
lation and other protein foods as already indicated, may be 
eaten. All vegetables that are soft and non-irritating, fats, 
particularly butter and oils and cream. All carbohydrate 
foods are easily digested as the gastric ptyalin digestion pro- 
ceeds uninterruptedly in the absence of gastric acidity. At 
the same time excessive use of sweets should be avoided as 
likely to disturb digestion. All simple desserts may be used 
to advantage. 

There is still another condition which must be reckoned 
with in these patients, namely, that while the gastric motility 
is usually well preserved in all but cancer cases, there may be 
the opposite condition of gastric atony. In this latter com- 



346 DIET IN DISEASES OF THE STOMACH 

plication one may use the same class of foods as recommended 
for the cases with good motility, but they should be given in 
smaller amounts and at more frequent intervals, following 
generally the dietetic rules laid down for atony, particularly 
with reference to restricted fluids at meals. 

Many of these cases of achylia are complicated by diarrhea 
probably of pancreatic origin, at all events there are few 
more brilliant results in medicine than those obtained in 
most of these cases of achylia diarrhea by the giving of 
dilute HC1, either alone or with pepsin; and all cases of 
unexplained and long-standing diarrhea should have deter- 
mined, by a gastric test meal, the presence or absence of 
HC1. 

The addition of this dilute acid to the dietary in all cases 
of achylia is of distinct advantage, although it must not be 
given in too large doses and later when digestion is regulated 
it may be possible to omit the acid altogether. 

GASTRITIS. 

Acute Gastritis. — Acute gastritis, except that caused by 
a toxicosis, must be considered a rare disease, in spite of the 
frequency of the diagnosis. When the toxicosis is constitu- 
tional of course the dietary treatment is along lines laid down 
for the particular disease at fault, e. g., renal insufficiency, 
etc. There are however, a fair number of cases caused by 
the direct effect of irritating substances such as strong acids, 
alkalies and abuse of condiments, but most frequent of all, 
the excessive use of alcohol; and it is after a drinking bout 
that this is most frequently met with. In any case, the 
cause being what it may, the dietary treatment is practically 
the same. 

The first step is starvation, nothing whatever should be 
given by mouth and the fluids which the system craves in 
severe cases accompanied by much nausea and vomiting, 
may be supplied by the rectum, either in the form of a Murphy 
drip or by giving from six to eight ounces of warm saline 
by rectum, every two, three or four hours. After twelve 'to 
twenty-four hours, or when the vomiting has ceased, one may 
begin to feed small amounts of cold peptonized milk, or kou- 
myss, buttermilk, white of egg in dilute orange juice beaten 
up and strained; milk; Vichy or Delafield's mixture: 1 be- 
ginning all in very' small amounts (a teaspoonful every 
twenty to thirty minutes) and increasing the amount and 

1 Delafield's mixture: Cream, 120 c. c. (oz. 4); milk, 120 c. c. (oz. 4); Vichy, 
120 c. c. (oz. 4); soda bicaronate, gm. % (gr. 20); cerium oxalate, gm. j^ (gr. ioj. 



GASTRITIS 347 

lengthening the interval. In certain cases, small amounts 
of iced champagne or ice-cold ginger ale are well borne and 
may even be of assistance in controlling the vomiting. 

In acute gastritis or esophagitis, due to taking a corrosive 
poison, demulcent drinks are of especial value in not only 
supplying some nourishment, but in quieting an inflamed 
mucous membrane. Of these drinks' a thin solution of gum 
arabic (2 to 5 per cent.) flavored with a little orange juice is 
acceptable. Also a solution of Iceland moss made in the 
same way. After the acute stage is past one begins with 
gruels, fine cereals, milk, plain or diluted; then soft solids 
and so on up the scale until the full diet is reached. All 
rough, highly spiced and peppery, very hot or very cold 
foods and drinks should be avoided for some time. 

Chronic Gastritis. — In contradistinction to the acute vari- 
ety, chronic gastritis is fairly frequently seen and is practi- 
cally always secondary to a chronic disease with poor elimi- 
nation, to chronic congestion, as in hepatic cirrhosis or car- 
diac decompensation or a chronic form of irritation of which 
latter, of course, alcohol is the chief example. During an 
acute exacerbation the diet should be the same as that de- 
tailed for acute gastritis. When the disease is found in its 
later stages many digestive symptoms are traceable to its 
presence. In arranging the diet for such cases it is almost 
absolutely essential to have an analysis of a gastric test meal 
for diagnosis, as many digestive symptoms referred to the 
stomach and lumped as chronic gastritis are nothing of the 
sort. They are quite as likely due to secretory or motor 
disturbances, often secondary to other conditions such as 
peptic ulcer, chronic appendicitis or gall-bladder disease, 
and have nothing to do with an increased production of 
mucus, which is a sine qui non of true gastritis. 

Then too, some cases of chronic gastritis are accompanied 
by hyperacidity, others by normal or hypoacidity running 
even into an achylia gastrica, the certain knowledge of which 
will be of great assistance in selecting a proper dietary. 

In general it may be said that after removal of the cause, 
whenever that is possible, a certain amount of rest and the 
entire absence of all irritating food should be insisted upon. 

Diet. — When the gastritis is accompanied by hyperacidity, 
the following articles of food should be forbidden : 

Salt foods, spiced foods, acid foods, rough or mechanically 
irritating foods, fermented foods, e. g., wines, beers and ales. 
Of course, no case of gastritis should take alcohol in any 
form except possibly when the patient has been long ac- 
customed to its use, a little whiskey or red wine, both diluted 



348 DIET IN DISEASES OF THE STOMACH 

with Vichy, may be allowed for a short time. Nothing very 
hot or very cold is allowed. On the other hand, as there is 
usually good digestive power to the secretions, a fairly high 
protein allowance of a non-stimulating sort may be allowed. 
In a general way the diet may be advised as follows: 

Early morning on awakening a half-glass of warm Hopital 
or Celestin Vichy, or water with half a teaspoonful of arti- 
ficial Vichy salts. This taken at least one-half hour before 
breakfast, acts as does a gastric lavage. If the bowels are 
constipated an occasional small dose of some of the laxative 
soda salts may be given, phosphate or sulphate of soda. 

Breakfast: Cocoa, made with milk, or weak tea; fine 
cereal — farina, cream of wheat, wheatena with 
cream, and very little sugar; soft toast or soft part 
of stale bread, well chewed; eggs in any simple 
form. Later, apple sauce or baked sweet apple. 
Luncheon, Dinner or Supper: Cream or puree soup (no 
meat stock). Simple egg entree. A little boiled 
chicken or young lamb, scraped or finely cut beef, 
all without rich gravies or sauces; puree of soft, 
green vegetables, put through a colander, without 
seeds or rough cellulose or skins; cauliflower, cab- 
bage or tomatoes are not allowed, desserts, soft 
custards, puddings, gelatin desserts with cream, 
cream desserts; ice-cream occasionally. Later soft 
stewed fruits, not acid, and cooked with little sugar; 
junket. 
Beverages: Alkaline waters, Vichy, High Rock, plain 
water; cocoa or weak tea; milk. 
Milk food should be reduced to a minimum in the presence 
of gastric atony. The quantity of food given at each feed- 
ing and the length of the feeding interval will depend on the 
condition of gastric motility. When this is good, three 
normal-sized meals may be given, when impaired, frequent, 
small, dry feedings are better. This is of course, true of 
gastritis by whatever degree of acidity it is accompanied. 
(See Diet in Gastric Atony.) It is advisable to eat a meal 
which is easily digested and passed into the intestine as 
rapidly as possible, so giving the maximum degree of rest 
to the stomach. 

Diet when Gastritis is Accompanied by Hypoacidity or 
Achylia. — Early morning alkaline waters as for hyperacid 
cases, except that to them, may be added a little sodium 
chloride; or Carlsbad water or sodium salts may be allowed 
when constipation is present, or plain water, six ounces 
(180 c.c.) with salt gr. v (y£ gm.), soda bicarbonate gr. xv 



PEPTIC ULCER (GASTRIC AND DUODENAL) 349 

(i gm.). The chief difference in the diet from that given 
for hyperacid cases is that less meat protein is allowed. 
Stewed fruits may be used earlier than in hyperacid cases 
and stock soups are permitted largely for their appetizing 
qualities. With impaired motility, however, soup of all 
kinds is best omitted, as fluids then leave the stomach slowly. 
Water should be taken in only small amounts with meals 
and it is well to order patients to drink water about an hour 
before meals, between meals and at bedtime. 

PEPTIC ULCER (GASTRIC AND DUODENAL). 

In the acute and so-called medical ulcer of the stomach or 
duodenum or in the acute exacerbation of a chronic ulcer, 
the management and dietary are the chief essentials, except- 
ing, of course, those cases which on account of some compli- 
cation demand surgical intervention. In response to this 
need, there have sprung up a number of different forms of 
treatment, some advocates of all of them being found in 
each community. The fact that the acute medical ulcer 
has a tendency to heal spontaneously, if given a fair chance, 
probably accounts for the claims of one or another of the 
different methods in vogue. With the acute exacerbation 
of a chronic ulcer it is somewhat different and although the 
acute symptoms may promptly subside when treated as an 
acute simple ulcer, the ultimate end sought, namely cicatri- 
zation of the old ulcer is a most uncertain chance, although 
it does take place in perhaps a larger proportion of cases than 
the surgeons would have us believe, as proved by autopsy 
findings. The gastric and duodenal ulcers are dealt with 
together, as their dietary treatment is identical. 

The Chief Methods of Dietary Treatment for ulcer may 
be classed as: 

1. Absolute physiological rest to the upper digestive tract, 
with later mouth feedings either with or without rectal 
alimentation in addition. 

2. Almost continuous, but reduced, physiological activity 
of the stomach but with food that is in small amounts, 
principally protein and which has the quality of quickly 
binding the free hydrochloric acid, turning the albumin into 
the comparatively unirritating syntonin, and of leaving the 
stomach quite promptly. 

3. Transgastric or duodenal feedings. 

4. An essential feature of still another form of treatment 
is the use of alkalies to reduce the exaggerated acidity, usu- 
ally present in these cases, together with the feeding of small 



350 DIET IN DISEASES OF THE STOMACH 

quantities at frequent intervals of highly albuminous foods. 
The use of alkalies may, of course be combined with any one 
of the forms of treatment and has many advocates. 

The first plan has the disadvantage, if carried out to the 
letter, of almost complete starvation during the time of 
digestive rest. Where this has been modified by attempts at 
rectal feeding or water is introduced by rectum, physiology 
has shown that at once peristaltic unrest is set up through- 
out the entire gastro-intestinal tract and it also gives rise 
to gastric secretion, although this is denied by some 
authorities. 

Von Leube Diet in Ulcer. — In the first type of diet as 
exemplified by the von Leube cure and modified most satis- 
factorily by G. R. Lockwood, absolute rest is given for three 
days and not even water is allowed, but the mouth is kept 
moist by mouth washes. If after twenty- four to forty- 
eight hours the thirst becomes too excessive, the Murphy 
drip is instituted whereby from twenty to fifty drops of nor- 
mal saline solution are allowed to flow into the rectum each 
minute, depending on the patient's rectal tolerance. To 
this Murphy drip there may be added sufficient glucose to 
make a 2 per cent, solution. It also helps to make the 
patient relaxed, and comfortable to add 50 grains (3.5 gm.) 
strontium bromide to the day's allowance. If given con- 
tinuously about three pints of fluid may be introduced into 
the system preventing absolutely the thirst which is so try- 
ing. In patients who are old, feeble or desiccated by vomit- 
ing and insufficient food before hand, the first period of starv- 
ation is limited to twenty-four hours. 

On the second day in these cases, and the third day in 
sthenic cases, 2 ounces of Celestin or Hopital Vichy is given 
every two hours and the following day this is alternated 
with 2 ounces of albumin water, so that liquids are there- 
fore given every hour. Von Leube also recommends very 
strongly the continuous use of local heat over the upper 
abdomen either as hot compresses or the use of the electric 
pad over a moist compress, except in cases of recent hemor- 
rhage. On the next day fully peptonized milk, 2 ounces at 
each feeding, every two hours is alternated with the Vichy 
so that the patient gets one or the other every hour. Dur- 
ing the first few days of this diet, if the thirst is troublesome, 
either the Murphy drip can be continued or from 4 to 6 
ounces of warm saline may be given by rectum every three 
or four hours. Each day the peptonized milk is increased 1 
ounce, until 8 ounces are being taken. The Vichy is increased 
1 ounce daily until 4 ounces are given at a time. Both 



PEPTIC ULCER (GASTRIC AND DUODENAL) 351 

Vichy and fully peptonized milk 1 have been shown by Can- 
non to leave the stomach very rapidly. The bowels are 
kept regular by enemeta and if there is troublesome gastric 
acidity, alkaline powders are given. About the tenth day 
soft milk toast, junket or fine cereal may be added. It is 
well to add these to one of the peptonized milk feedings, 
then to two, three or until with every other milk feeding the 
patient gets a soft solid. When a soft solid is given it is 
better not to give over 4 oz. (120 c.c.) of the peptonized 
milk. In the third week, the quantities may be increased 
and creamed mashed potato, fresh creamed halibut or cod 
fish, macaroni, puree soups made without meat stock are 
added, also puree of vegetables, such as puree of peas. 
Farinaceous desserts can then be added, such as cornstarch, 
farina, blanc mange and custard. During these three weeks 
the patient remains in bed, still continuing the hot appli- 
cations. During the fourth w^eek they may be allowed up 
in a chair and put gradually on any soft food, leaving out 
fruit, coffee, acids, irritants of all kinds, whether mechanical, 
thermal or chemical. 

This dietary cure takes time and cannot be hurried if one 
wishes to give the patient the best chance of recovery. 
When the mouth feedings have begun some clinicians pre- 
fer to use nutrient enemata as an additional supply of fluid 
and some nourishment. The best food for this purpose is 
undoubtedly fully peptonized milk, the same as that given 
by mouth with or without the addition of glucose sufficient 
to make a 2 to 4 per cent, solution. Often the milk alone is 
better borne in varying quantities, some patients taking as 
much as 1 pint every six hours, others a less amount at more 
frequent intervals, all of which must be determined for each 
case individually. (For details see Rectal Feeding.) 

Those who prefer to use the von Leube diet as originally 
outlined by him, will find the following plan useful. 

Von Leube's Diet 2 (Original): 
First Three Days: 

7 a.m. 150 c.c. of milk (5 oz.). 

8 A.M. 150 c.c. of milk (5 oz.). 

10 A.M. 150 c.c. of milk (5 oz.) with strained barley 
water. 

^or complete peptonization of milk, Lockwood's directions are most satis- 
factory. Divide a quart of milk in half, bring one-half (i pt.) to boiling 
and add the other cold pint. This produces the correct temperature. To this 
add two tubes of Fairchild's peptonizing powder rubbed up in 4 ounces of 
water. Put the milk in scalded bottles and stand in a pail of water at 105 
F. and keep there with occasional shaking for two hours. Then scald and 
put on ice. 

2 Smith: What to Eat and Why, p. 193. 



352 DIET IN DISEASES OF THE STOMACH 

ii a.m. 150 c.c. of milk (5 oz.). 
1 p.m. 150 c.c. bouillon with peptone preparation. 
Fourth to Eleventh Day: 
7 to 9 a.m. 300 c.c. of milk (10 oz.). 

11 a.m. 300 c.c. of milk with barley, rice or oatmeal 
water. 
1 p.m. One cup of bouillon (200 c.c.) with a beaten egg. 
3 to 5 P.M. 300 c.c of milk (10 oz.). 
7 p.m. Milk with barley water. 
9 p.m. 300 c.c. of milk (10 oz.). 
Eleventh to Fourteenth Day: 

7 to 9 A.M. 300 c.c. of milk (10 oz.) and two crackers, soft- 
ened with barley water. 
11 a.m. 300 c.c. of milk (10 oz.). 
1 p.m. 200 c.c. bouillon (6^ oz,), one egg, two crackers. 
3 p.m. 300 c.c. of milk (10 oz.), one egg. 
5 p.m. 300 c.c. of milk (10 oz.), two crackers. 
7 p.m. Milk with barley water. 
9 p.m. 300 c.c. of milk (10 oz.). 
Fourteenth to Seventeenth Day: 
7 to 9 to 11 a.m. As above. 

1 p.m. Scraped meat 50 gm. (i%oz.), two crackers, one 
cup of bullion, 200 c.c. {6y 6 oz.). 

3 P.M. 300 c.c. of milk (10 oz.). 

5 p.m. 300 c.c. of milk (10 oz.), one soft-boiled egg, two 

crackers. 
7 p.m. 300 c.c. of milk (10 oz.) with farina. 
9 p.m. 300 c.c. of milk (10 oz.). 
Seventeenth to Twenty -fourth Day: 

7 a.m. Two soft-boiled eggs, butter (1 gm.), toasted 

bread 50 gm. (1% oz.), 300 c.c. of milk (10 

oz.). 
10 A.M. 300 c.c. of milk (10 oz.), crackers 50 gm. (1% oz.). 
1 p.m. Broiled lamb chop 50 gm. (1% oz.), mashed 

potato 50 gm. {1% oz.), butter 10 gm. (}i 

oz.), cup of bouillon 200 c.c. (6}4 oz.). 

4 p.m. Same as 10 a.m. 

6.30 p.m. 300 c.c. (10 oz.), of milk with farina, crackers 

50 gm. (1% oz.j, butter 20 gm. (% oz.). 

9 p.m. 300 c.c. milk (10 oz.). 

Of the second method of feeding these cases, viz., that of 

continued physiological activity with small amounts of bland 

and highly albuminous food, the Lenhartz diet is the best 

known and most generally used. One great object of this 

diet is to do away with any period of actual starvation, on 

the principle that the better nourished a patient can be kept 



PEPTIC ULCER {GASTRIC AND DUODENAL) 353 

the greater chance for healing. In addition, what has 
already been said, in regard to the favorable influence of 
the rapid combining of the free hydrochloric acid with the 
albumin in the diet, of which there is great abundance, holds 
true. 

General Directions for Lenhartz's Diet.. — Patients must 
be in bed and kept there the entire time not even allowed up 
for use of the commode; naturally the best and sunniest 
room available should be chosen for all of these cases, re- 
gardless of the form of diet. 

The eggs used in each day's feedings should be beaten up 
raw and divided equally into seven feedings, putting the 
feedings into seven medicine or small glasses for accuracy 
and keeping them all in the ice-box until used. The milk 
used for the day should be put on ice and the feeding spoon 
kept on ice. All feedings should be very slowly given by 
spoonfuls. A very little salt may be allowed on the egg 
feedings, otherwise none. As will be seen from the schedule 
of feedings, they are given every hour from 7.00 A.M. to 7.00 
p.m., or 8.00 a.m. to 8.00 p.m. if more convenient, leaving 
a full twelve-hour rest. The following are the details of 
each day's diet. 

First Day 



7.00 A.M. 
8.00 A.M. 


Egg. 
Milk, 


20 c.c. (% oz.). 


9.00 A.M. 
10.00 A.M. 


Egg. 
Milk, 


20 C.C. (% OZ.). 


11.00 A.M. 
12.00 NOON 


Egg. 
Milk, 


15 c.c. (Koz.). 


1. 00 P.M. 


Egg. 




2.00 P.M. 


Milk, 


15 c.c. (y 2 oz.). 


3.00 P.M. 
4.OO P.M. 


Egg. 
Milk, 


15 c.c. (y 2 oz.). 


5.00 P.M. 
6.00 P.M. 


Egg. 
Milk, 


15 c.c. (y 2 oz.). 


7.00 P.M. Egg. 
Total, first day, eggs (raw), 2; milk, 
calories, 280. 






Second Day 


7.00 A.M. 
8.00 A.M. 


Egg. 
Milk, 


35 c.c. (1 oz.). 


9.00 A.M. 
10.00 A.M. 


Egg. 
Milk, 


35 c.c. (1 oz.). 


11.00 A.M. 


Egg. 




12.00 NOON 


Milk, 


35 c.c. (1 oz.). 


1. 00 P.M. 


Egg. 




23 







100 c.c. (2Ai oz -); 



354 DIET IN DISEASES OF THE STOMACH 

2.00 p.m. Milk, 35 c.c. (i oz.). 

3.00 p.m. Egg. 

4.00 p.m. Milk, 35 c.c. (1 oz.).. 

5.00 p.m. Egg. 

6.00 p.m. Milk, 30 c.c. (1 oz.). 

7.00 p.m. Egg. 

Total second day, eggs (raw), 3; milk, 200 c.c. (6%oz.); 
calories, 470. 

Thtrd Day 

7.00 a.m. Egg; sugar, 2 gm. {yi dr.). 

8.00 a.m. Milk, 50 c.c. (1% oz.). 

9.00 A.M. Egg; sugar, 3 gm. (^ dr.). 

10.00 a.m. Milk, 50 c.c. (1% oz.). 

11.00 a.m. Egg; sugar, 3 gm. {y A dr.). 

12.00 noon Milk, 50 c.c. (1% oz.). 

1.00 p.m. Egg; sugar, 3 gm. {y A dr.). 

2.00 p.m. Milk, 50 c.c. (1% oz.). 

3.00 p.m. Egg; sugar, 3 gm. (^ dr.). 

4.00 p.m. Milk, 50 c.c. (1% oz.). 

5.00 p.m. Egg; sugar, 3 gm. (J< dr.). 

6.00 p.m. Milk, 50 c.c. (1% oz.). 

7.00 p.m. Egg; sugar, 3 gm. (^ dr.). 
Total, third day, eggs (raw), 4; milk, 300 c.c. (10 oz.); 
sugar, 20 gm. (5 dr.) ; calories, 637. 

Fourth Day. 

7.00 a.m. Egg; sugar, 2 gm. (yi dr.). 

8.00 a.m. Milk, 70 c.c. (23^ oz.). 

9.00 a.m. Egg; sugar, 3 gm. (J< dr.). 

10.00 a.m. Milk, 70 c.c. (2}4 oz.). 

11.00 a.m. Egg; sugar, 3 gm. {y A dr.). 

12.00 noon Milk, 65 c.c. (2 oz.). 

1. 00 p.m. Egg; sugar, 3 gm. (^ dr.). 

2.00 p.m. Milk, 65 c.c. (2 oz.). 

3.00 p.m. Egg; sugar, 3 gm. (X dr.). 

4.00 p.m. Milk, 65 c.c. (2 oz.). 

5.00 P.M. Egg; sugar, 3 gm. (J< dr.). 

6.00 p.m. Milk, 65 c.c. (2 oz.). 

7.00 p.m. Egg; sugar, 3 gm. (fi dr.). 
Total fourth day, eggs (raw), 5; milk, 400 c.c. (13H oz.); 
sugar, 20 gm. (5 dr.) ; calories, yyy. 

Fifth Day 

7.00 A.M. Egg; sugar, 4 gm. (1 dr.). 

8.00 a.m. Milk, 80 c.c. (2% oz.). 

9.00 a.m. Egg, sugar, 4 gm. (1 dr.). 



PEPTIC ULCER {GASTRIC AND DUODENAL) 355 

10.00 a.m. Milk, 80 c.c. (2% oz.). 

11.00 A.M. Egg; sugar, 4 gm. (1 dr.). 

12.00 noon Milk, 80 c.c. (2% oz.). 

1. 00 p.m. Egg; sugar, 4^ gm. (1 dr.). * 

2.00 p.m. Milk, 80 c.c. {2% oz.). 

3.00 p.m. Egg; sugar, \)/ 2 gm. (1 dr.). 

4.00 p.m. Milk, 80 c.c. (2% oz.). 

5.00 p.m. Egg; sugar, 4^ gm. (1 dr.) 

6.00 p.m. Milk, 90 c.c. (3 oz.). 

7.00 P.M. Egg; sugar, \]/ 2 gm. (1 dr.). 

Total, fifth day, eggs (raw), 6; milk, 500 c.c. (16% oz.); 
sugar, 30 gm. (1 oz.); calories, 966. 

Sixth Day 

7.00 A.M. Egg; sugar, 4 gm. (1 dr.). 

8.00 a.m. Milk, 100 c.c. (sH oz.). 

9.00 a.m. Egg; sugar, 4^ gm. (1 dr.); scraped beef, 

12 gm. (3 dr.). 
10.00 a.m. Milk, 100 c.c. (33^ oz.). 

11.00 a.m. Egg; sugar, \Y 2 gm. (1 dr.). 

12.00 noon Milk, 100 c.c. (33^ oz.). 
1. 00 p.m. Egg; sugar, 4^ gm. (1 dr.); scraped beef, 

12 gm. (3 dr.). 
2.00 p.m. Milk, 100 c.c. (3H oz.). 

3.00 p.m. Egg; sugar, \]/ 2 gm. (1 dr.). 

4.00 p.m. Milk, 100 c.c. (33^ oz.). 

5.00 p.m. Egg; sugar, 4 gm. (1 dr.); scraped beef, 

12 gm. (3 dr.). 
6.00 p.m. Milk, 100 c.c. (3^ oz.). 

7.00 p.m. Egg; sugar, \Y 2 gm. (1 dr.). 

Total, sixth day, eggs (raw), 7; milk, 600 c.c. (20 oz.); 
sugar, 30 gm. (1 oz.; scraped beef, 36 gm. (9 dr.); calories 
II35- 

Seventh Day 

7.00 a.m. 1 soft-boiled egg. 

8.00 a.m. Milk, 100 c.c. (33^ oz.). 

9.00 a.m. Egg; sugar, 13 gm. ( 3 dr.). 

10.00 a.m. Milk, 100 c.c. (3M Qz.); scraped beef, 23 

gm. (6 dr.); boiled rice, 33 gm. (1 oz.). 
.11.00 a.m. 1 soft-boiled egg. 

12.00 noon Milk, 125 c.c. (4 oz.). 

1.00 p.m. Egg; sugar, 13 gm. (3 dr.). 

2.00P.M. Milk, 125 c.c. (4 oz.); scraped beef, 23 

gm. (6 dr.); boiled rice, 33 gm. (1 oz.). 

3.00 p.m. 1 soft-boiled egg. 



356 DIET IN DISEASES OF THE STOMACH 

4.00 p.m. Milk, 125 c.c. (4 oz.). 

5.00 p.m. Egg; sugar, 14 gm. (33^ dr.). 

6.00P.M. Milk, 125 c.c. (4 oz.); scraped beef, 24 

gm. (6 dr.); boiled rice, 34 gm. (1 oz.). 
7.00 p.m. 1 soft-boiled egg. 

Total, seventh day, eggs (raw), 4; soft-boiled, 4; milk, 
700 c.c. (233^ oz.); sugar, 40 gm. (ij^ oz.) ; sraped beef, 
70 gm. (23/3 oz.); boiled rice, 100 gm. (33/3 oz.), with beef 
juice; calories, 1580. 

Eighth Day 
The diet changes on the eighth day, requiring only four 
raw eggs, which may be divided into three feedings. The 
other four eggs are to be soft-boiled and given as directed 
by diet. 

7.00 a.m. 1 soft-boiled egg. 

8.00 a.m. Milk, 135 c.c. (4^ oz.). 

9.00 a.m. Egg; sugar, 13 gm. (3 dr.). 

10.00 a.m. Milk, 133 c.c. {\Y 2 oz.); scraped beef, 23 

gm. (6 dr.); boiled rice, 33 gm. (1 oz.). 
11.00 A.M. 1 soft-boiled egg; zweiback, 10 gm. {2]/ 2 

dr.). 
12.00 noon Milk, 133 c.c. (4^ oz.). 
1.00 p.m. Egg; sugar, 13 gm. (3 dr.). 

2.00 p.m. Milk, 133 c.c. (4^ oz.); scraped beef, 23 

gm. (6 dr.); boiled rice, 33 gm. (1 oz.). 
3.00 p.m. 1 soft-boiled egg. 

4.00 p.m. Milk, 133 c.c. (\Y 2 oz.). 

5.00 p.m. Egg; sugar, 14 gm. (3^ dr.); zweiback, 

10 gm. (2 l /i dr.). 
6.00 P.M. Milk, 133 c.c. (4^ oz.) ; scraped beef, 24 

gm. (6 dr.); boiled rice, 34 gm. (1 oz.). 
7.00 p.m. 1 soft-boiled egg. 

Total eighth day, eggs (raw), 4; soft-boiled, 4; milk, 800 
c.c. (26% oz.); scraped beef, 70 gm. (2^ oz.); boiled rice, 
100 gm. (3^ oz.); zweiback, 20 gm. (5 dr.); sugar, 40 gm. 
(i}4 oz 0; calories, 1720. 

Ninth Day 
7.00 a.m. 1 soft-boiled egg. 

8.00 a.m. Milk, 150 c.c. (5 oz.). 

9.00 A.M. Egg; sugar, 13 gm. (3 dr.). 

10.00 a.m. Milk, 150 c.c. (5 oz.); scraped beef, 23 gm. 

(6 dr.); boiled rice, 66 gm. (2 oz.). 
11.00 a.m. 1 soft-boiled egg; zweiback, 20 gm. (5 dr.). 

12.00 noon Milk, 150 c.c. (5 oz.). 
1. 00 p.m. Egg; sugar, 13 gm. (3 dr.). 



PEPTIC ULCER (GASTRIC AND DUODENAL) 357 

2.00 p.m. Milk, 150 c.c. (5 oz.); scraped beef, 23 gm. 

(6 dr.); boiled rice, 67 gm. (2 oz.). 
3.00 p.m. 1 soft-boiled egg; zweiback, 20 gm. (5 dr.). 

4.00 p.m. Milk, 150 c.c. (5 oz.). 

5.00 p.m. Egg; sugar, 14 gm. (3^ dr.) 

6.00 p.m. Milk, 150 c.c. (5 oz.); scraped beef, 24 

gm. (6 dr.); boiled rice, 67 gm. (2 oz.). 
7.00 p.m. 1 soft-boiled egg. 

Total, ninth day, eggs (raw), 4; cooked, 4; milk, 900 c.c. 
(30 oz.); sugar, 40 gm. (13^ oz.); scraped beef, 70 gm. (23^ 
oz.); rice, 200 gm. (6% oz.); zweiback, 40 gm. (13^ oz.) or 
toast, 20 gm. (dr.); calories, 2138. 

Tenth Day 

7.00 a.m. i soft-boiled egg. 

8.00 a.m. Milk, 166 c.c. ($y 2 oz.). 

9.00 a.m. Egg; sugar, 13 gm. (3 dr.). 

10.00 a.m. Milk, 168 c.c. (^/i. oz.); scraped beef, 23 

gm. (6 dr.) ; boiled rice, 66 gm. (2 oz.). 
11.00 a.m. 1 soft-boiled egg; zwieback, 20 gm. (5 dr.); 

butter, 4 gm. (1 dr.). 
12.00 NOON Cooked chopped chicken, 25 gm. (6 dr.); 
milk, 166 c.c. {$y 2 oz.). 
1. 00 p.m. Egg; sugar, 13 gm. (3 dr.). 

2.00 p.m. Milk, 166 c.c. {$y 2 oz.); scraped 'beef, 23 

gm. (6 dr.); boiled rice, 66 gm. (2 oz.); 
butter, 4 gm. (1 dr.). 
3.00 p.m. 1 soft-boiled egg; zwieback, 20 gm. (5 dr.); 

butter, 4 gm. (1 dr.). 
4.00 p.m. Cooked chopped chicken, 25 gm. (6 dr.). 

5.00 p.m. Egg; sugar, 14 gm. (3^ dr.). 

6.00 p.m. Milk, 166 c.c. ($y oz.); scraped beef, 24 

gm. (6 dr.); boiled rice, 67 gm. (2 oz.); 
butter, 4 gm. (1 dr.). 
7.00 p.m. 1 soft-boiled egg. 

Total, tenth day, eggs (raw), 4; cooked, 4; milk, 1000 
c - c - (33H oz.); sugar, 40 gm. (\]4 oz.) ; scraped beef, 70 gm. 
gm. (2\i oz.); boiled rice, 200 gm. (6% oz.); zwieback, 40 
gm. (ij^ oz.), or toast, 20 gm. (5 dr.); chicken, 50 gm. (\% 
oz.); butter, 20 gm. (5 dr.); calories, 2478. 

Eleventh Day 

7.00 a.m. I soft-boiled egg; milk, 250 c.c. (8J^ oz.); 

zwieback, 10 gm. (2^ dr.); butter, 4 

gm. (1 dr.). 
8.00 A.M. Egg; sugar, 13 gm. (3 dr.); scraped beef, 

20 gm. (5 dr.) ; boiled rice, 75 gm. (2^ 

oz.); zwieback, 10 gm. {2.y 2 dr.); butter, 

6 gm. (iy dr.). 



358 DIET IN DISEASES OF THE STOMACH 

n.oo p.m. i soft-boiled egg; milk 250 c.c. (8J£ oz.) ; 

butter, 6 gm. V/2 dr.); zweiback, 10 gm. 
(2-^ dr.). 
1. 00 p.m. Egg; sugar, 13 gm. (3 dr.) ; cooked chopped 

chicken, 25 gm. (6 dr.); boiled rice, 75 
gm. (2^ oz.). 
3.00 p.m. 1 soft-boiled egg; milk, 250 c.c. (8}4 oz.) ; 

scraped beef, 20 gm. (5 dr.) ; boiled rice, 
75 gm. (2.y 2 oz.); zwieback, 10 gm. (2^ 
dr.); butter, 6 gm. (iyi dr.). 
5.00 p.m. Egg; sugar, 14 gm. (3^ dr.); cooked chop- 

ped chicken, 25 gm. (6 dr.) ; boiled rice, 
75 gm. (2y 2 oz.); butter, 6 gm. {\]/ 2 dr.). 
7.00 p.m. 1 soft-boiled egg; milk, 250 c.c. (8J^oz.); 

zwieback, 10 gm. {2)/ 2 dr.); butter, 6 
gm. (iyi dr.) ; scraped beef, 30 gm. (1 oz.) 
Total, eleventh day, eggs (raw), 4; cooked, 4; milk, 1000 
cc. (33^ oz.); butter, 40 gm. (\\i oz.) ; sugar^o gm. (ij^ 
oz.); scraped beef, 70 gm. (2j^ oz.) ; boiled rice, 300 gm. 
(10 oz.); zwieback, 60 gm. (2 oz.); chicken, 50 gm. (1% 
oz.) ; calories, 2941. 

Twelfth Day 

7.00 a.m. i soft-boiled egg; milk, 250 c.c. (8J^ oz.) ; 

zwieback, 10 gm. (2^ dr.); butter, 4 
gm. (1 dr.). 

9.00 a.m. Egg; sugar, 13 gm. (3 dr.); scraped beef, 

35 gm. (1 oz.); boiled rice, 75 gm. {2]/ 2 
oz.); zwieback, 10 gm. (2}4 dr.); butter, 
6 gm. (i}4 dr.). 
1 1. 00 a.m. 1 soft-boiled egg; milk, 250 c.c. (8}i oz.) ; 

zwieback, 20 gm. (5 dr.) ; butter, 6 gm. 
iH dr.). 

1. 00 p.m. Egg; sugar, 13 gm. (3 dr.); cooked chopped 

chicken, 25 gm. (6 dr.); boiled rice, 75 
gm. {2}4 oz.); zwieback, 10 gm. [2]/ 2 
dr.); butter, 6 gm. (i}4 dr.). 

3.00 p.m. 1 soft-boiled egg; milk, 250 c.c. (8}4 oz.); 

scraped beef, 35 gm. (1 oz.) ; boiled rice, 
50 gm. (1% oz.); zwieback, 10 gm. 
(2}4 dr.); butter, 6 gm. {\]/ 2 dr.). 

5.00 p.m. Egg; sugar, 14 gm. (3^ dr.); cooked chop- 

ped chicken, 25 gm. (6 dr.); boiled rice, 
75 gm. (2]/ 2 oz.); zwieback, 10 gm. (2^ 
dr.); butter, 6 gm. (i}4 dr.). 



PEPTIC ULCER {GASTRIC AND DUODENAL) 359 

7.00 p.m. i soft-boiled egg; milk, 250 c.c. (S}4 oz.); 

zwieback, 10 gm. (2)4 dr.); butter, 6 

gm. (i)4 dr.). 

Total, twelfth day, eggs (raw), 4; cooked, 4; milk, 1000 

cc. (33H oz.); sugar, 40 gm. (1}^ oz.); scraped beef, 70 

gm. (23^ oz.); boiled rice, 300 gm. (10 oz.); zwieback, 80 

gm. (2% oz.); chicken, 50 gm. (1% oz.) ; abutter, 40 gm. 

(i)4 oz.); calories, 2941. 

Thirteenth Day 

7.00 a.m. 1 soft-boiled egg; milk, 142 c.c. (4^3 oz.); 

zwieback, 10 gm. (2)4 dr.); butter, 4 

gm. (1 dr.). 
9.00 A.M. Egg; sugar, 13 gm. (3 dr.); milk, 142 c.c. 

(4% oz.) ; scraped beef, 20 gm. (5 dr.) ; 

boiled rice, 75 gm. (2)4 oz.) ; zwieback, 

20 gm. (5 dr.); butter, 6 gm. (\)4 dr.). 
11.00 a.m. 1 soft-boiled egg; milk, 144 c.c. (5 oz.); 

zwieback, 10 gm. {2% dr.) ; butter, 6 

gm. (i)4 dr.). 
1. 00 p.m. Egg; sugar, 13 gm. (3 dr.); milk, 142 c.c. 

(4% oz.); cooked chopped chicken, 25 

gm. (6 dr.); boiled rice, 75 gm. (2)4 oz.); 

zwieback, 10 gm. (2)4 dr.); butter, 6 

gm. (i)4 dr.). 
3.00 p.m. 1 soft-boiled egg; milk, 144 c.c. (5 oz.); 

scraped beef, 20 gm. (5 dr.) ; boiled rice, 

75 gm. (2)4 oz.) ; zwieback, 10 gm. {2)4 

dr.); butter, 6 gm. (i)4 dr.). 
5.00 p.m. Egg; sugar, 14 gm. (3^ dr.); milk, 142 

c.c. (5 oz.) ; cooked chopped chicken, 25 

gm. (6 dr.) ; boiled rice, 75 gm. (2)4 oz.) ; 

zwieback, 10 gm. (2)4 dr.); butter, 6 

gm. (i)4 dr.). 
7.00 p.m. 1 soft-boiled egg; milk, 144 c.c. (5 oz.); 

zwieback, 10 gm. (2)4 dr.); butter, 6 

gm. (i)4 dr.). 
Total, thirteenth day, eggs (raw), 4; cooked, 4; milk, 
1000 c.c. (333^3 oz-); sugar, 40 gm. (i}4 oz.) ; scraped beef, 
70 gm. (23/3 oz.); boiled rice, 300 gm. (10 oz.); zwieback, 
80 gm. (2^3 oz.); chicken, 50 gm. (1% oz.); butter, 40 gm. 
(1 y z oz.) ; calories, 3007. 

Fourteenth Day 

7.00 a.m. i soft-boiled egg; minced chop; buttered 

toast; milk, 142 c.c. (4% oz.). 



360 DIET IN DISEASES OF THE STOMACH 

9.00 a.m. Boiled rice; buttered zwieback; custard; 

milk, 142 c.c. (4.% oz.). 
11.00 a.m. J 1 soft-boiled egg; buttered zwieback; jun- 
ket; milk, 144 c.c. (5 oz.). 
1. 00 p.m. Minced chicken; boiled rice; buttered zwie- 

back; custard; milk, 142 c.c. (4% oz.). 
3.00 p.m. 1 soft-boiled egg; cooked scraped beef; 

boiled rice; buttered toast; milk, 144 c.c. 
(5 oz.). 
5.00 p.m. Minced chicken; boiled rice; buttered zwie- 

back; custard; milk, 142 c.c. (4% oz.).- 
7.00 p.m. 1 soft-boiled egg; buttered toast ; milk, 144 

c.c. (5 oz.). 
Total, fourteenth day, eggs (raw), 4; cooked, 4; milk, 
1000 c.c. (33M oz -); sugar, 40 gm. (ij^ oz.) ; scraped beef, 
70 gm. (23^ oz.); boiled rice, 300 gm. (10 oz.); zwieback, 
100 gm. (33^ oz.); butter, 40 gm. (1^ oz.); chicken, 50 gm. 
(1% oz.); calories, 3007. 

Many patients are unable to take the full amount of food 
ordered after the sixth day, particularly women who may 
have long been small eaters. If pushed, the feedings may 
result in an acute gastric upset, anorexia, nausea, vomiting; 
in fact this has been very frequent in the writer's experience, 
often making it necessary to stop all feedings for twenty- 
four hours or at least, after the sixth day only advancing 
the diet every other day, thus giving a little more time to 
become adjusted to the quantity of food. In fact this is the 
writer's custom whenever this form of diet seems indicated. 
Whenever any hard substance like zwieback is called for, 
it is wiser to substitute a little softened toast or even the 
zwieback softened with hot water. 

The usefulness of the Lenhartz diet is confined almost 
entirely to the treatment of acute ulcer cases and even in 
these the amount of food given after the first few days is 
too large for most patients, nausea and vomiting being, 
not infrequently, the result. 

In chronic ulcer it is distinctly less valuable for the same 
reason and also because meat is added too early to the diet. 
Diet Combined with Alkaline Treatment. — There have 
been advanced many forms of the alkaline treatment com- 
bined with proper diet for cases of gastric and duodenal 
ulcer, but apparently the one most specifically and carefully 
worked out for this is the treatment arranged and practised 
by B. W. Sippy 1 of Chicago. By this method he feels that 
an operative procedure is scarcely ever necessary, as the 

1 Sippy, in Musser and Kelly: Jour. Am. Med. Assn, 1915, lxiv, 20, 1625. 



PEPTIC ULCER {GASTRIC AND DUODENAL) 361 



if s 



C3 



■9S 



T3 S 



J & 



W S 
3 SO 
W 







s 






N 


N 


N 






a 






o 


o 


O 












X 5 


NOT 


\P0 






















^— ' 






*-— ' 


> — ' 


s — ' 






c 






o 


O 


o 






IO 






m 


lO 


m 






_ 






^ 





^_^ 






N 






N 


N 


N 













O 


o 


o 












X 


X 


£ 






s — ' 






v — ' 


v — ' 


*~s 






O 






o 


o 


o 






o< 






**- 


Tt- 


"* 


<-N C 




^-^ 









^^ 


^^ 


N 04 






CN 










o . 




o 






'-"■* 


o 


o 


SP5 w 

rt \ crj 


si 

o 


\M 


~f. 


N 
O 


o 


NOT 




C- ° 






z 




0* 


<N 


N 


O lH 




o 


)_, 




O 


o 


O 


Tt- O 




rt- o 




vO 


OC 


00 



N 


N 


N 


N 


N 


N 


N 


o 


O 


o 


o 


o 


o 


o 


X 


X 


<N\ 




o 


o 


c 


CO 


CO 


vO 


VO 









o o o o o o 

o o o o c o 

•i cn o) co co co 



— 4; N N N N N N N 

H .o -00000000 



Ov CN CM CM <N (N CN CS 



w ooooocoo 

cor^r^r^r^r^r^r^ 



NNN N N N N N N 

ooo c o o o o o 



|#J l/J HH M M l-i (-1 HH 1-1 M HH 

ooooo o o o o o o 

N N CO CO ^ rj- ^- t^ <^- ^f- Tf 

^ ^ ^ ^ s~, ^ ^ _ _ _ ^ ^ ^ >. 

NNNNNNN N N N N N N t> 

ooooooc o o o o o o 



^°cOvOOcovOOcO vO O co co co co 

m i-h i-c C« W W CO CO CO CO co 

ooooooo o o o o o o 

oooocco o o o o c o 

i-ioicori-iovor^ oo o> c o o o 



CN co "t- iO ^0 t^. rf rj- ^ ^ ^- Tt- rt- rj- rf- Th rj-^- ^-rj- 

£ £ £ £ £ £ ££ ££ za ££ %£ *£ ££ 

rt cS rt rt rt c3 crj O c3 O rj O rtO crj O nJO rt O 

rv> p^ jV (V p^ p/ P^ M C^ W pv^ "^3 P^" 3 C^ ^ Ch M C^ '^ 



o o 

o o 

CO co 



vO 


lO 





vO 


CO 


oo 


o\ 


i -1 


ir; 



362 DIET IN DISEASES OF THE STOMACH 

cases are so regularly cured by medical means, and he even 
includes all cases of pyloric stenosis, except those of extreme 
narrowing, due to definite cicatricial contraction following a 
healed ulcer. He says that after three, four or more weeks 
of this treatment the spasm is relieved, the round-celled 
infiltration disappears as well as the edema of the inflamma- 
tory tissues, and the lumen is again established so that in 
practically every case a motor meal, consisting of meat and 
vegetables, leaves the stomach within the normal limits of 
six or seven hours. This is of course, quite radical and might 
be considered an extreme statement; Sippy, however, is 
most definite in his statements as to methods, what is to be 
expected and the results obtained, and since they are made 
on such responsible authority they warrant a respectful 
hearing and a very thorough trial in practice. He limits 
surgical interference in ulcer cases to the following condi- 
tions and complications. 

1. Perforation. 

2. Perigastric abscess. 

3. Secondary carcinoma. 

4. Hour-glass or other deformity. 

5. Hemorrhage of a serious nature under certain condi- 
tions. 

6. Pyloric obstruction of high grade not influenced by 
medical treatment. 

The underlying principles on which the diet and treatment 
are founded may be stated as follows: Peptic ulcers would 
tend to heal spontaneously, as ulcers situated elsewhere, were 
it not for the fact that they are constantly subjected to the 
corrosive action of the gastric juice and that if this can be 
neutralized continuously during the period of gastric and 
upper intestinal digestion by proper diet and alkalies and the 
removal at night of any product of continuous hypersecre- 
tion, the ulcer will heal without difficulty. With this as a 
basis, Sippy treats and diets these cases as follows: 

"Patients are put to bed from three to four weeks, at the 
end of which time they are gradually allowed up and out as 
one would after any illness of a corresponding length, but no 
real work should be attempted for a period of seven or eight 
weeks at least. As originally outlined the initial treatment 
consists of a period of five davs in which no food or drink was 
given by mouth, but about twelve ounces, more or less, of 
saline was given by rectum four times a day. Subsequently, 
this period of starvation was abandoned, and presumably, 
except in the case of severe hemorrhage, the feedings were 
begun at once. Each morning one-half hour before the 



PEPTIC ULCER (GASTRIC AND DUODENAL) 363 

first feeding a dram of subnitrate of bismuth is given in a 
little water. Feedings are given every hour from 7 a.m. to 
7 p.m., consisting of equal parts of milk and cream in amounts 
of a total of 1 to 3 ounces. Although acidity is more easily 
controlled by hourly feedings, some cases do well on two, 
three or four hourly feedings. Half-way between each feed- 
ing a powder consisting of 10 grains each of calcined magnesia 
and sodium bicarbonate is given, alternating with another 
powder of 10 grains of bismuth and 20 to 30 grains of soda 
bicarbonate. It is best to give the powder containing mag- 
nesia as often as possible as the magnesia has four times the 
power of neutralizing the free hydrochloric acid as compared 
with the soda; diarrhea, however, is apt to follow its free 
use, so that one must alternate these powders according to 
this condition. After two or three days, soft eggs and well- 
cooked (fine) cereals are added so that at the end of about 
ten days the patients are receiving the 3 ounces of milk and 
cream mixture every hour from 7 A.M. to 7 p.m., 3 soft- 
boiled eggs, one at a time, and 9 ounces of cereal, 3 ounces 
given at each of three feedings. These extras are added one 
at a time until the six extra feedings of eggs and cereals are 
given evenly spaced throughout the day. The bulk of each 
feeding should not exceed a total of 6 ounces. In order 
that the treatment should be successful, an accurate control 
of the acidity must be maintained throughout the twenty- 
four hours. This is accomplished by testing the gastric 
contents from time to time, early in the treatment, by the 
stomach-tube (or Einhorn's duodenal tube may be used to 
advantage, as very easy of application). Sippy's method 
for accurate control of the free hydrochloric acidity is some- 
what as follows: the first day or two the tube is passed 
occasionally to check up the presence of free HC1; if present 
in the stomach contents the alkali powders must be increased 
as the treatment aim absolutely to keep the free HC1 down 
to zero. After a day or two this is done as a routine two or 
three times a week, as practically that is all that is necessary 
to insure the absence of the hydrochloric acid. 

"The amount of alkali can be varied as determined by the 
examination of the stomach contents. It is particularly 
necessary to be sure that the stomach does not contain free 
acid during the night and it may be necessary to give two or 
three alkali powders between 7 and 10 p.m. to insure this. 
At 10 o'clock the tube should be passed and all acid hyperse- 
cetion removed. If there is a considerable amount of this, 
the tube should be passed again during the night two or three 
times. After the first few day's treatment this is rarely 



364 DIET IN DISEASES OF THE STOMACH 

necessary as the hypersecretion is usually well controlled 
and at 10 p.m. nothing but a very few c.c. of gastric contents 
are found, which are unimportant. 

"In the diet cream soups, vegetable purees or other soft 
foods may be added or substituted, such as jellies, custards, 
creams; keeping, however, the milk, cream, eggs and cereal 
as the basis of the diet. The best cereals are farina, cream 
of wheat, rice cooked to a soft pulp. With this diet it is 
quite regularly that the cases, according to Sippy, show a 
gain of from I to 4 pounds a week. 

"During the third week, soft toast or crackers, puree of 
potato, cream soups may be added. In the fourth week the 
milk and cream may be made 2.yi ounces each at each feed- 
ing and the period between feedings lengthened to two hours. 
After two or three weeks more, three-hour feedings may be 
given, but if the ulcer is of some month's duration it is best 
not to increase the periods too rapidly and for several months 
it is wise not to have the patients take less than five feedings 
a day. The morning bismuth should be taken for from six 
to eight weeks and then stopped and the alkaline powders 
should be continued between feedings for several months. 

" During a period of a year or more, milk, cream, eggs, 
vegetables, purees, cereal, bread and butter and meats 
should form the basis of the diet." In cases that for one 
reason or another milk is distasteful, it often can be given if 
flavored with tea, cocoa, etc., frozen balls of butter may 
be substituted for cream and a small quantity of cereal 
gruel may be given each hour. 

Modified Diet for Peptic Ulcer. — In this the essential 
features of both the Sippy and von Leube methods are com- 
bined and fully peptonized milk (two hour peptonization) 
is used instead of the milk and cream mixture of Sippy. 
This modified method reproduces medically the conditions 
that are sought by operation, viz., a continued greatly re- 
duced gastric acidity and even a real alkalinity of the stom- 
ach contents, as well as a rapid emptying time, for Canon 
has shown that fully peptonized milk leaves the stomach 
with great rapidity. 

The following are the details of the method. 

The patient is kept in bed for three weeks and the hot 
pad kept continuously on the epigastrium as in the von 
Leube routine. The continuous Murphy drip of 2 per 
cent, glucose solution is started at once to which is added 50 
grains (3 gm.) strontium bromide for the daily allowance. 
Nothing by mouth is allowed for three days. Mouth washes 
are used several times a day. Mouth feeding is begun on 



PEPTIC ULCER {GASTRIC AND D UODENAL) 365 

the fourth day, consisting of 2 oz. (60 c.c.) fully peptonized 
milk, every hour from 7 a.m. to 7 p.m. Half way between 
feedings the alkaline powders, as recommended in the Sippy 
routine, are given in two ounces of water (60 c.c). Each 
day the milk is increased one ounce (30 c.c.) until four ounces 
(120 c.c.) are taken every hour, (or eight ounces (240 c.c.) 
every two hours in some cases). The water allowance is 
not increased to over three or four ounces (90 to 120 c.c.) with 
the alkalie. After eight or ten days of feeding, a tablespoon- 
ful of well cooked farina is allowed, first twice a day with 
two milk feedings which are kept up continuously. The 
tenth day farina, cream of wheat or wheatena are allowed 
with three of the milk feedings. The twelfth day one may 
increase the cereal to two tablespoonfuls and a small sprink- 
ling of powdered sugar is allowed. The fifteenth day four 
soft feedings are given evenly spaced throughout the day, 
still continuing the peptonized milk feedings; of these soft 
feedings one may be, one slice of milk toast. The seven- 
teenth day a soft egg is allowed or custard and the milk 
feedings may be reduced to 2 oz. (60 c.c). After the twenty- 
first day, the feedings are arranged so as to give three soft 
meals at eight, one at six-thirty with a mid-feeding at eleven 
a.m. and four p.m. of milk, custard, junket or cream cheese 
sandwich. In the fourth week creamed fresh cod or halibut 
are added, cream or puree soups, mashed potatoes and well 
cooked rice. 

From the end of the third week the peptonization of the 
milk is reduced fifteen minutes a day until plain milkistaken 
but always scalded. During the entire treatment the alkal- 
ine mixtures are given in sufficient amount at first to maintain 
as nearly as possible a continuously alkaline reaction to the 
gastric contents and when soft feedings are added sufficient 
to prevent the formation of free HC1 at least. The stomach 
contents must be tested by passing a stomach or duodenal 
tube and emptying the stomach at bed time and during the 
night if necessary, as recommended in the Sippy routine. 

Ambulatory Diet Cure for Peptic Ulcer. — There are 
always a certain number of cases that are seen in whom the 
symptoms are very suggestive of chronic ulcer, but in whom 
the diagnosis is not sufficiently certain or for one reason or 
another the patients will not or cannot give the time for a 
regular course of treatment in bed. In these cases it is ad- 
visable to put them on a bland diet which has sufficient food 
value to keep up the patient's strength, and combine well 
with the usual large excess of free hydrochloric acid and- be 
obtainable almost any and everywhere. In this day of the 



366 DIET IN DISEASES OF THE STOMACH 

"dairy lunch," it is very easy to obtain this diet anywhere 
about a city. If the case is actually one of gastric or duo- 
denal ulcer the chances are very great that at least there will 
be decided temporary relief, sometimes for a year or more 
and in a few cases, particularly if persisted in for three or 
four weeks, the writer has seen clinical cures. The diet is 
also of considerable diagnostic value, as the case which is 
clinically ulcer but does not get very great or complete 
temporary relief for weeks or longer, is very probably not 
ulcer but chronic appendicitis, gall-bladder disease or some- 
thing else which simulates ulcer. 

The diet for these ambulatory cases is planned as follows: 
For two (or more) full weeks, they take at 8 a.m., i and 7 
p.m., 2 glasses of milk (]i cream) and 2 soft-boiled eggs 
(1 minute), without salt at first. At 11 a.m. and 4 P.M. 
i}4 glasses of milk (1680 c.c). 

This gives milk 56 oz. 

Cream 13 oz. (390 c.c.) 6 eggs. 

Protein 105 gm. (3^ oz.) ; fat 177 gm. (6 oz.). 

Carbohydrate 85 gm. (3 oz.) calories 2400. 

Before breakfast a dram (4 gm.) of bismuth subnitrate is 
given in an ounce of water. One half hour after the three 
principal meals, ^ to 1 dram (2 to 4 gm.) of the following 
powder; equal parts of bismuth, soda bicarbonate and cal- 
cined magnesia, is given in four ounces (120 c.c, of water. 
The magnesia may be reduced and an equal amount of soda 
added if the bowels are made too active by the magnesia. 
One half hour after the 11 a.m. and 4 p.m. feedings one tea- 
spoonful of soda is given in yi glass of water. At night 
after the seven o'clock feeding the magnesia mixture is given 
at 7.45 and a teaspoonful of soda at 8.45 p.m. and 9.45 p.m., 
each in yi to % glass of water. 

If possible it is well for the patient to empty his stomach 
by the tube at 10.30. p.m. 

In all these forms of ulcer treatment, except when there 
has been a recent hemorrhage, if pain persists relief is often 
obtained by an early morning lavage of the stomach with a 
silver nitrate solution 1 : 4000 increasing to 1 : 2000 followed 
after the stomach is left clean by plain water lavage by the 
bismuth. 

After the two weeks are up, or longer in severe cases, fine 
well-cooked cereals, custards, gruels, cream soups, soft toast; 
later boiled fish, etc., can be added as in the third and 
fourth weeks of the von Leube diet. 

One does not expect to get the best results with this diet 
and it should not be advised unless the patient refuses for 



PEPTIC ULCER (GASTRIC AND DUODENAL) 367 

one reason or another to take a full course of diet with rest 
in bed. Vichy is the best form in which to take water be- 
tween feedings or if more alkali is indicated by much acidity. 
Alkali powders may be given an hour to an hour and a half 
after the principal feedings. If the milk mixture does not 
seem to agree, some of the alkali may be added directly, to 
each feeding. 3 An occasional case has to omit the cream 
on account of increased gastric acidity. 

Transgastric or Duodenal Feeding. 2 — This method of feed- 
ing has been devised by Einhorn and is recommended by 
him in gastric or duodenal ulcer cases or chronic gastric 
dilatation, to prevent weight on the gastric walls and to allow 
them to contract down to more nearly their normal size, 
this of course provided there is no organic obstruction. Also 
in extreme atony, whether there is pylorospasm or not; in 
cases where nutrition is difficult on account of asthenia, 
absolute anorexia and nervous vomiting. Einhorn also 
recommends it in severe liver diseases to reduce the physio- 
logical congestion of that organ and also in inoperable car- 
cinoma of the stomach where the taking of food is painful. 

In gastric or duodenal ulcer with which we are particu- 
larly concerned here, its usefulness is claimed to lie in the 
rest, both secretory and muscular,which it gives to the stom- 
ach and possibly to a less extent to the duodenum. 

The duodenal tube is introduced as follows: The tube is 
put in the patient's mouth and he is given a swallow or more 
of water, to wash it down, taking care only that it is not 
swallowed too quickly, so that it does not rotate on itself, 
but will go straight into the stomach. The patient then 
lies on the right side to facilitate the passage of the tube into 
the duodenum by gravity. This takes a varying amount of 
time, depending on the acidity present, the motor power of 
the stomach muscle and the presence or absence of pyloro- 
spasm, entering the duodenum quickest in hypoacidity or 
achylia when accompanied, as it usually is, by good muscu- 
lar action and no spasm of the pylorus; the time varying 
from ten to twenty minutes under the latter conditions, to 
two or three hours for normal individuals and even up to 
thirty-six hours at the longest. When the tube is beyond 
the pylorus it is difficult to obtain fluid and what little can 
be obtained is alkaline and usually contains bile. If still in 
the stomach the fluid aspirated by the syringe is of course 

X A very good form of alkaline powder to use is equal parts of soda bicarbonate, 
heavy burned magnesia and subnitrate of bismuth. Bismuth subnitrate in dram 
doses is useful to control pain when given on an empty stomach early in the 
morning. 

2 Einhorn: Post Graduate, 1913. 



368 DIET IN DISEASES OF THE STOMACH 

acid and is in greater quantity. If there is achylia and 
consequently no acid to test for, we can give a little milk or 
colored fluid by mouth and immediately aspirate : if the tube 
is beyond the pylorus no milk will be aspirated. After the 
tube is once in the duodenum it is left there throughout the 
period of feeding, twelve to fifteen days, and the mouth 
kept clean by frequent use of mouth washes. 

The regular feedings recommended by Einhorn consist of 
milk, 7 or 8 ounces, (210 to 240 c.c.) one egg and a tablespoon- 
ful of lactose. If diarrhea develops the lactose is omitted. 
Where it is necessary to prevent loss of weight or to increase 
weight, 1 or 2 drams(2 to 4 gm.) of butter to each feeding may 
be added. Where patients for one reason or another cannot 
take milk, gruels may be substituted but always being sure 
that the feedings are all free from lumps. The number of 
feedings is eight a day at two-hour intervals and must be 
given slowly, taking at least twenty minutes to each; for if 
given rapidly they cause overdistention of the duodenum and 
great discomfort. The best way to introduce the food is by 
means of a syringe with a three-way stopcock so that it need 
not be disconnected each time. 

The food should all be strained and given at body tem- 
perature and the thinner the tube the more comfortable for 
the patient, although the smaller tubes necessitate slower 
feeding. A very important rule is, that after the food has 
been given, a little water, then a little air should be passed 
through the tube to be sure the tube is clean and empty; 
otherwise the tube is apt to be blocked in a day or two, 
necessitating its removal for cleaning. Besides the feed- 
ings at least a pint of warm normal saline should be given 
once a day, or this may be given by rectum. After the period 
of transgastric feedings is finished one begins mouth feedings 
with fully peptonized milk, then soft thin cereals and gradu- 
ally increases the feeding as recommended in the von Leube 
cure, only one need not begin with such small feedings, but 
the feeding recommended for the eighth feeding day may be 
used at the start and increased as indicated for that regimen. 

Duodenal Feeding Diet. (Einhorn.) 
7.30 a.m. Oatmeal gruel 180 c.c. (6 oz.) 

One egg 

Butter 15 gm. ( y 2 oz.) 

Lactose 15 gm. ( K oz.) 

9. 30 a.m. Pea soup 180 c.c. (6 oz.) 

One egg 

Butter 15 gm. ( K oz.) 

Lactose 15 gm. ( l / 2 oz.) 

t 1 . 30 a.m. Same as at 9.30 a.m. 
1.30 p.m. Bouillon 180 c.c. (6 oz.) 

One egg 



DIE T A FTER HEMORRHA GE FROM STOMA CH 369 

3.30 p.m. Oatmeal gruel 180 c.c. (6 oz.) 

Butter 15 gm. ( y£ oz.) 

One egg 

Lactose 15 gm. ( T / 2 oz.) 

5 . 30 p.m. Same as at 9.30 A.M. 

9.30 p.m. Bouillon 180 c.c. (6 oz.) 

One egg 
Total amount: Calories. 

Oatmeal gruel 360 c.c. (13 oz.) = 1476 

Eggs 8 = 1352 

Pea soup 720 c.c. (26 oz.) = 384 

Lactose 90 gm. ( 3 oz.) = 369 

Bouillon 360 c.c. (13 oz.) = 39 

Butter 90 gm. ( 3 oz.) = 715 



4335 



DIET AFTER HEMORRHAGE FROM STOMACH OR 

DUODENUM. 

At the first evidence of hemorrhage the patient is to be 
kept absolutely at rest and quiet in bed. If the hemorrhage 
is severe so that life is threatened either from exsanguina- 
tion or cerebral anemia, the foot of the bed should be ele- 
vated on shock blocks and the patient's limbs tied off with 
broad bandages to keep as much blood in the trunk and head 
as possible. Each limb should be left tied off not longer 
than ten minutes at a time, they can be used thus in rota- 
tion, one or two at a time. Absolutely nothing should be 
given by mouth, not even cracked ice, but if there has been 
great loss of blood, saline may be given by rectum either in 
4- to 6-ounce amounts, every three or four hours or by 
continuous Murphy drip. If the hemorrhage is extreme a 
saline infusion may be given or better still a blood trans- 
fusion from a suitable donor. If the hemorrhage is recur- 
ring and too excessive, the question of immediate laparo- 
tomy must be considered. 

After hemorrhage, it is best, if possible, not to use rectal 
saline or feeding for at least twenty-four to forty-eight hours 
unless the thirst becomes too excessive. The chief reason 
is, that anything put into the rectum starts antiperistalsis 
which may reach the stomach, and also that it is capable 
of starting gastric secretion. After this period is past one 
may begin on one or two lines of treatment. 

1. Feeding by rectum entirely, for from two to five days, 
or even longer, and then begin on the Lenhartz or von Leube 
diets. 

2. By beginning at once with a Lenhartz or von Leube 
diet, as already explained. In the author's opinion the Len- 
hartz is better suited to acute ulcerative conditions than to 

24 



370 DIET IN DISEASES OF THE STOMACH 

chronic, while the von Leube, particularly as modified by 
Lockwood, is better for either condition, acute or chronic. 
From this point the diet is arranged in accordance with the 
details of the diet selected. Practically all clinicians of 
experience favor at least a period of twenty-four to forty- 
eight hours' absoute rest to the stomach before food or even 
water is given by mouth. 

GASTRIC ATONY. 

(Impaired Gastric Motor Function or Myasthenia 

Gastric a.) 

Enough has been said of this condition of atony when 
complicating chronic gastritis to indicate quite fully the 
principles involved in prescribing a dietary for the use of 
patients suffering from motor insufficiency of the stomach. 

Since the condition is almost always secondary to a general 
muscular and nervous debility often found in patients after 
exhausting or long-continued disease, and in those of enter- 
optotic habitus, the greatest care must be exercised in choos- 
ing a diet in order to overnourish these patients, if possible, 
so that they can gain in general ways, while at the same time 
preventing gastric overdistention and the introduction of 
foods which leave the stomach slowly or with difficulty, 
such as all coarse or tough foods, heavy fats, etc. 

Many patients with motor insufficiency of the stomach get 
fixed ideas as to what they can or cannot eat and since it is 
usually the latter, they very quickly add to their troubles 
marked malnutrition and eventually settling down to a die- 
tary which is hopelessly inadequate to nourish them, with 
the result that their stomach musculature becomes still 
further weakened. 

Motor insufficiency has been termed by some authorities 
as "an indigestion of liquids" which simply means that 
liquids remain in the stomach longer than solids in this con- 
dition, so giving rise to fulness, splashing and regurgitation 
for a longer or shorter time after the stomach should be nor- 
mally empty. It must also be kept in mind that many if 
not most of these patients show general improvement, when 
on a proper diet, a considerable time before the gastric 
muscle regains its tone and they are constantly tempted to 
break rules and eat or drink as they choose because they 
feel so much better and stronger; only a firm adherence to 
diet and general hygiene with graduated exercises will bring 
the desired result with a return to normal of the gastric 
functions. Associated with the myasthenia one finds very 



GASTRIC ATONY 371 

frequently a condition of gastric hyperacidity which must 
also be taken into consideration in the diet planned for these 
individuals, also many persons with congenital or acquired 
ptosis of the stomach show the same combination of patho- 
logical conditions, namely, myasthenia and hyperacidity, 
either separately or combined. 

General Directions in Gastric Atony. — Before touching 
directly on the foods best suited to these cases it would be 
worth while to formulate certain rules for these patients to 
follow, which will aid the stomach in performing its motor 
functions with the greatest efficiency under the individual 
circumstances. 

i. Patients should always have a period of absolute rest 
before meals, reclining for fifteen to thirty minutes. It is 
astonishing how much this rest will improve the appetite and 
muscular tone, it means that they eat when rested and do 
not hurry in to a meal from some occupation; this is one of 
the greatest aids to good digestion in any abnormal condi- 
tion of the gastro-intestinal tract. 

2. Meals should be small, well-cooked and of easily di- 
gested materials, rather dry and of concentrated caloric 
value, without skins of fruit and vegetable seeds, gristle or 
fat which does not melt at body temperature, e. g., mutton 
fat. 

3. The interval for feeding in severe cases should be every 
three hours; 3 or 4 ounces or more of water should be given 
three-quarters of an hour before meals, best at room tem- 
perature or warm, never cold. 

4. At meals it is best to take no liquids or at most not over 
3 ounces and then only in the less severe cases. 

5. It should be remembered that milk often fails to agree 
with these patients, increasing flatulence. 

6. After meals when possible (and always in severe cases), 
patients should lie for half an hour to an hour on their right 
side in order to facilitate evacuation of the stomach by 
gravity. 

7. Many cases, particularly those complicated by gastro- 
ptosis will get great digestive benefit by wearing a proper 
corset or belt. This helps to fix a usually flabby abdominal 
wall and improves the splanchnic circulation, often result- 
ing in a general increase of the systolic blood-pressure ; such 
patients often having an abnormally low arterial tension, 
85 to 100 mm. Hg. 

8. Other hygienic measures useful in this condition will be 
found in books dealing with this particular subject, e. g., 
exercises, bathing, sleep and rest. 



372 DIET IN DISEASES OF THE STOMACH 

Keeping in mind the foregoing rules it would hardly seem 
necessary to give a specimen dietary for such a case, but 
many are too busy or lack enthusiasm for these details, hence 
the following sample diets are given with the caution that 
such conditions as hyperacidity or hypoacidity, fermentation, 
pyloric spasm, etc., must be recognized if present and due 
allowance made in the selection of a diet (see Special Rules 
for Diet in Hyper- and Hypoacid Gastric Conditions). 
Diets for Atony: (Rather liberal). 
7 a.m. 2 tablespoonfuls of any well-cooked cereal with 
butter and sugar (heavy cream if it agrees). 
Bread or toast and butter, two slices; i soft- 
boiled egg. 
io A.M. Custard (unsweetened) with cream, 2 or 3 toasted 
saltines. 
1 p.m. Chopped meat or chicken or fish; bread and but- 
ter; rice, cooked to a pulp, with butter and 
salt, or beef juice or baked potato. Later a 
small portion of baked hubbard squash, stewed 
celery, or rice or bread pudding, but both 
dessert and vegetables should not be taken at 
the same meal. 
4 p.m. Cream cheese with toasted and buttered saltine 
biscuits, as a sandwich, one or two of these. 

7 p.m. Fish or eggs (except fried), bread and butter, 

rice with butter and cream, a simple dessert 
such as custard, blanc mange, Spanish cream, 
etc. 

10 p.m. Same as 10 a.m. or 4 p.m., feedings or a plain 

sandwich made of beef, chicken or mutton; 

Swiss cheese, bread and butter. 
For those who can take milk, it may be used in various 
ways, plain, buttermilk or junket, etc. Many of these cases 
of myasthenia being merely a part of a general neurasthenia 
with malnutrition, do well on the Wier-Mitchell rest cure 
routine, care only being taken that large quantities of food 
shall not be taken at one time. In the severe cases it is 
often best to feed every two hours instead of every three, 
using small feedings of concentrated nourishment, then 
gradually increasing, the intervals of feeding and the quan- 
tity of food at each feeding. 
Diet for Severe Atony: 

8 a.m. Junket, 240 c.c. (8 oz.), with cream, 60 c.c. 

(2 oz.). 

1 1 a.m. 4 saltines, with cream and cheese. 
1 p.m. Sandwich of bread and beef. 



GASTRIC ATONY 373 

4 p.m. Cocoa, junket, 360 c.c. (12 oz.). 

7 p.m. Custard, baked or boiled, 180 gm. (6 oz.). 

9 p.m. Sandwich, with chicken and bread. 

Wegele's Diet for Atony of the Stomach: 

Morning. — Dry toast, 30 gm. (1 oz.) ; a cupful of cocoa 
made of leguminose cocoa and 60 gm. (2 oz.) of cream. 

Forenoon. — An egg (poached or soft-boiled) and 30 gm. 
(1 oz.) of toast. 

Midday.- — Scraped meat, 100 gm. (3^ oz.) ; mashed po- 
tato, 7 oz. (210 gm.); toast, 30 gm. (1 oz.) ; followed by 30 
gm. (1 oz.) of extract of malt. 

Afternoon. — A cupful of cocoa with 60 c.c. (2 oz.) cream, 

Evening. — Tapioca cooked to a pulp, 300 gm. (10 oz.). 
Followed by 20 c.c. (^ oz.) of malt extract. 

10 p.m. — A tumblerful of milk with a dessertspoonful of 
cognac brandy. 

Tibbies, 1 on the other hand, recommends only three meals 
at 8 a.m., 2 p.m. and 8 p.m., two of them mainly protein, 
giving most of the carbohydrate at midday, as follows: 

Breakfast, 8 a.m. — Fish (sole, haddock, weakfish, seabass, 
halibut), with a little lemon juice; 1 or 2 eggs poached or 
lightly boiled. A small amount of crisp dry toast or stale 
bread, and a cupful of coffee with cream and one piece of 
sugar (if it agrees). 

Midday. — 2 p.m. (No meat.) Boiled macaroni with a 
trace of grated cheese or boiled rice with tomato, puree of 
cabbage, savory or potato with gravy or extract of meat; 
boiled spinach, vegetable marrow or squash, string or snap 
kidney beans. Any milk pudding which has been cooked 
slowly (four or five hours). Jellies or creams made with 
gelatin, or fruit jelly or cooked apples, plums, prunes and 
raw fruit rubbed through a sieve (raspberries, strawberries, 
blackberries or currants). At the end of the meal 4 or 5 
ounces of water, diluted spirit, Burgundy or Bordeaux. 

Evening. — 8 p.m. Soup about 90 c.c. (3 oz.) ; fish (same 
as at breakfast), tender lean beef or mutton, poultry, veni- 
son, pheasant or other game (except hare); 30 gm. (1 oz.) 
of potato puree or boiled rice or toast or stalebread ; no pud- 
ding or dessert. At the end of meal 2 glasses of wine or 30 
c.c. (1 oz.) of whiskey in 120 c.c. (4 oz.) of water. The 
food has a heat value of 2150 calories and contains: 

Protein. Fat. Carbohydrates. Alcohol. 

209.6 gm. 58.7 gm. 142.5 gm. 35 c.c. 

1 Dietetics, Lea & Febiger, p. 295. 



II 
I 


A.M. 
P.M. 


4 

7 


P.M. 
P.M. 



374 DIET IN DISEASES OF THE STOMACH 

Diet for Mild Atony: 1 

8 a.m. Cup of coffee or cocoa, with cream, sugar, fine 
cereal. 
Egg shake, Russell's emulsion or koumyss. 
Steak or chop, one vegetable, rice pudding, 

bread and butter. 
Chicken sandwich and a glass of hot milk. 
Fish or chicken, two green vegetables, tapioca 
pudding. 

For advanced atony, still smaller meals are best, e. g.,\ 
8 a.m. Cup of coffee or cocoa with cream, sugar; soft- 
boiled egg, bread and butter. 
II a.m. Baked custard. 
I p.m. Minced chicken on toast, cornstarch pudding. 
4 P.M. Scraped beef sandwiches. 
7 p.m. Small broiled chop, creamed spaghetti, 
io p.m. Cup of malted milk. 

The same rules in regard to drinking as before outlined. 
Meals should be dry, never more than one glassful of fluid 
and better less, half a glassful between meals once or twice. 

ORGANIC GASTRIC ACIDITY. 

This may be of two sorts, one due to the ingestion of 
organic acids in foods, such as acetic acid in pickles, cider, 
vinegar or acid-wine preparations ; butyric acid from butter, 
lactic acid from buttermilk or other fermented or ripened 
milks. The other form of organic acidity is that due to the 
development of acids arising in the process of gastric fer- 
mentation, thus lactic acid from bacterial action on carbo- 
hydrates, butyric acid from dextrose and in fact any sugar, 
also from lactic acid. When gastric hydrochloric acidity 
is normal, bacterial activity is checked and organic acids 
are not found in the gastric contents unless they are ingested 
except in minimal amounts. 

The dietary treatment of organic acidity depends, of course, 
first on the prevention of the ingestion of the acids and then 
upon the omission from the diet of acid-forming bodies, such 
as wines, butter, sugar and starches. At times it is best to 
put the patient on a milk diet for two or three days, then to 
add eggs, meat, fish, green vegetables and fruits, but omit- 
ing all farinaceous foods for a time. When all symptoms 
have subsided, well-toasted bread or cereal food may be 
allowed once a day, then twice a day and later three times a 
day and so on until the patient is back to a full mixed die- 
tary. 

^ockwood: Diseases of the Stomach, p. 327. 



CARCINOMA OF THE STOMACH 375 

CARCINOMA OF THE STOMACH. 

The presence of a cancerous growth anywhere in the body 
is a guarantee that sooner or later the patient's nutrition will 
suffer and in spite of a sufficient intake these people lose 
weight out of apparent proportion to the size of the growth 
or indeed its location. To this rule there are numerous 
exceptions and all clinicians are familiar with the latent type 
of carcinoma that develops silently without giving the usual 
outward signs of nutritional disturbance until toward the 
end of the course of the disease. Some of these cases main- 
tain a remarkable degree of nutrition up to the end, but of 
course, most of them lose very rapidly as the disease pro- 
gresses and the emaciation in long-standing cases, particu- 
larly where the digestive tube is involved, is often extreme. 
The toxic destruction of tissue protein keeps a negative nitro- 
gen balance in spite of a high protein intake and when the 
amount taken is below the average normal, the emaciation 
is especially rapid. 

The partial or complete failure of free hydrochloric acid in 
the gastric secretion is an usual accompaniment of gastric 
carcinoma at some time in the course of its development, 
although it may not be evident in the earlier stages, but 
what is often lost sight of, is the fact that this same hypo- 
acidity may be present, when carcinoma is present at some 
point remote from the stomach. This fact has in all prob- 
ability much to do with the disturbances in digestion, as 
the lack of normal gastric secretion results not only in the 
lessening of gastric digestion but the normal stimulus for 
the pancreas and intestine is diminished or wanting and so 
the normal preparation of food-stuffs for absorption is in- 
terfered with, the results of which soon become evident. 

Diet in Carcinoma of the Stomach. — The<diet suitable for 
this disease depends principally upon the complications 
which may be present, and there are some fundamental facts 
which must be kept in mind. 

i. These cases of carcinoma on account of the hypoacidity 
should be given only moderate amounts of meat products, 
unless there are other further contra-indications. 

2. The gastric motility is apt to be disturbed with delayed 
emptying of the stomach, particularly in the later stages 
when this is present, it is necessary to diet according to the 
rules laid down for myasthenia gastrica (atony). 

3. When ulceration is evident one must be governed some- 
what by the principles advised for a peptic ulcer diet, in 
that the foods should be soft and non-irritating. It is not 



376 DIET IN DISEASES OF THE STOMACH 

necessary to reduce the quantity except in the presence of 
rather extreme ulceration, for there is no chance of healing 
a carcinomatous ulcer by diet, and it is most important to 
keep up the patient's nutrition to as high degree as possible, 
so these patients should be fed to the limit of their capacity 
with suitable liquids, semiliquids and soft foods. 

4. Where ulceration is extreme or the anorexia so severe 
that nutrition is interfered with out of proportion to the 
development of the growth, good results may be obtained 
by duodenal feedings, using liquid foods of high caloric 
value, as suggested under the chapter on Duodenal Feeding 
(p. 368). A fair amount can be done in this way to maintain 
the patient's weight and strength. 

The use of an early morning saline drink is especially good 
both for the cleansing effect on the gastric mucous membrane 
and for a laxative effect when this is necessary. Those 
waters with sodium chloride are good for their cleansing 
effect, particularly as there is usually an absence of chlorides 
in the stomach. Weisbaden or Carlsbad sprudel represent 
the two types, Weisbaden that without laxative effect and 
the Carlsbad when a laxative effect is needed. For most 
cases Vichy, either French or artificial, 4 ounces, does very 
well, or failing this, the use of 20 grains of soda bicarbonate 
and 10 grains of common salt in 6 ounces of water answers 
every purpose, with the addition of sodium sulphate or phos- 
phate when additional laxative effect is desired. 

Most of these patients crave food more highly seasoned 
than usual and there is no objection to this within reason. 

In the apparent absence of ulceration alcohol should be 
taken only sparingly on account of its tendency to disturb 
digestion. As an appetizer with meals, a little diluted wine 
or whiskey finds no contra-indication in fact unless, again 
ulceration is present. Foods that irritate or ferment readily 
should not be taken and are hardly likely to be, as anorexia 
is often a prominent symptom. 

When the growth involves either the cardia or pylorus, 
after a time only liquid food will pass a stricture. This food 
should be chosen with a view to its concentration as well as 
its fluid consistency and to this end milk, cream and lactose 
mixtures, with gruels made from cereals, pea soup with con- 
siderable amounts of butter, or puree soups in which cream 
is a large ingredient, and with ice-cream, made with eggs 
and liberally sweetened with lactose must form the bulk of 
the diet. In the preparation of milk to be used in the pres- 
ence of pyloric stenosis, it is well to boil it first then flavor it 
with cocoa, coffee, tea, etc., as boiling causes the curd to be 



CARCINOMA OF THE STOMACH 377 

fine and soft and to offer less difficulty in passing the pylorus. 
This is a necessary precaution, as even in the absence of 
normal gastric digestion whole milk will curd from what 
little acid there may be present, but the further chymifica- 
tion is interfered with on account of the diminished hydro- 
chloric acid and pepsin, so that the thick curd may remain in 
the stomach an indefinite length of time. Adding i or 2 
grains of sodium citrate to each ounce of milk has the effect 
also of preventing the formation of any but light flocculent 
curds. 

The liquid beef preparations are good as appetizers and 
for their stimulant effect, but their food value is so small 
that one must not be deceived by their bulk in thinking 
that anything of great food value is being given. The malted 
milk or dried-milk preparations are good to use for the sake 
of variety, but after all, the more normal the constituents 
of the diet can be kept the better the appetite and nutrition 
will be preserved. Any one of the predigested proteins is 
good to use. 

In the presence of hemorrhage, unless excessive, it is 
not wise to stop food for more than a few hours, although 
the quality and quantity of food taken afterward might 
better conform for a time to one of the peptic-ulcer diets, 
but as already stated, in connection with severe ulceration, 
the quantity must be rapidly advanced after a day or two 
of semistarvation, otherwise the loss of flesh and strength 
will be out of proportion to the uncertain improvement in 
the pathological condition present. 

When the pain from ulceration is so great as to cause great 
distress on the ingestion of food, it is well to give the patient 
a 5-grain orthoform tablet to dissolve in the mouth before 
meals or a small amount of cocaine in solution may be given, 
yi or 1 grain, but this should not be done regularly. Anes- 
thesin, 2 per cent., in olive oil may be given in ^-dram doses 
before meals, or bits of cracked ice with or without a little 
elixir of menthol 1 may add greatly to the patient's comfort 
if given before feedings. When the cancerous condition 
reaches this stage it is of course best to keep up a certain 
amount of morphine regularly, and the question of gastros- 
tomy o, gastroenterostomy must be considered as a tempor- 
izing measure. 

The relief to certain cases from these operations is, at 
times, exceedingly great, depending on the anatomical con- 
dition present, often permitting the patients to gain weight 

1 Elixir of menthol; Menthol i.o, Spts, Vin. 25.0, Aq. destil. and Syr. simpl. 
aa 12.0. 



378 DIET IN DISEASES OF THE STOMACH 

and a certain amount of well-being which may last several 
months before they finally succumb to the disease. When 
all else fails resort may be had to rectal feeding, but this, as 
already pointed out in the chapter on artificial modes of 
feeding, is inadequate in furnishing sufficient food to main- 
tain life for any considerable length of time, except at a low 
ebb, and acts as little more than a placebo, although suffi- 
cient fluid can be given to prevent great thirst and desiccation. 

GASTRIC DILATATION. 

In considering the question of gastric dilatation one natu- 
rally divides the condition into an obstructive and non- 
obstructive variety and again into an acute and chronic 
type. 

In the acute form whether from obstruction, such as an 
arteriomesenteric constriction, in very thin individuals, or 
obstruction due to acute kinking of the duodenum, or that 
due to paralytic causes, either central or peripheral, of which 
postoperative or postanesthetic, overdistention or toxic are 
the chief varieties, 1 the treatment is identical and so far as 
diet goes is quickly written. Give nothing whatever by 
mouth, neither food nor water. The former is not needed 
for a time and the latter may be supplied by rectal salines, 
or if necessary by hypodermoclysis. Lavage every two or 
three hours to remove the accumulated fluid with proper 
postural treatment with the patient lying well over on the 
right side or on the stomach are the forms of treatment 
needed. After it is seen that the dilatation has subsided 
and one no longer gets the characteristic brownish fluid by 
the stomach-tube, one can begin to feed small amounts of 
peptonized milk or gruel, gradually increasing the amount 
of food and the quality from fluid to semisolid and then to 
soft until after a period of three or four days to a week one 
can return to soft solid food, provided the general condition 
of the patient warrants it. 

In the chronic forms of dilatation, if this is due to obstruc- 
tion at the gastric outlet, one usually finds a good gastric 
muscle tonus, in fact it is often hypertonic, as the visible 
peristaltic waves testify ; but the difficulty is that the outlet 
is more or less narrowed so that first, heavy coarse articles 
of food fail to pass the obstruction, then later ordinary mixed 
or soft foods cannot leave the stomach completely and stag- 
nate, until finally, in the more advanced stage, even liquids 
cannot pass the pylorus. Of course before one considers 

jLockwood: Diseases of the Stomach, p. 335. 



GASTRIC NEUROSES 379 

dietetic treatment an accurate diagnosis is necessary for any 
intelligent mode of action. Having determined the degree 
of stenosis one gives a diet suitable for the underlying cause 
whether it be ulcer or simple cicatricial stenosis of varying 
degree. In the latter, if moderate, only soft diet finely 
divided, milk citrated to prevent a heavy curd (i grain 
sodium citrate to the ounce of milk) or boiled to the same end, 
may be given, with lavage at bedtime to prevent stagnation. 
In the more advanced cases when only fluids will pass one 
can use fully peptonized milk, puree soups, cream soups 
with butter and meat extract or meat jelly. Of course in 
such an instance of extreme stenosis, operative procedure 
must be contemplated and decided upon before the patient 
loses vitality and strength. If Sippy's claims are substan- 
tiated most of the cases due to ulcer and round-celled in- 
flammatory exudate recover without operation on the diet 
as outlined by him (see p. 360). Where the chronic dilata- 
tion is secondary to a general or gastric myasthenia the diet 
must be in accordance with that laid down for the dietetic 
treatment of atony (p. 372), and the principles of small dry 
meals with total reduction of fluid during the twenty-four hours 
to one quart, or at times less, must be adhered to. Certain 
authors recommend in this condition small feedings of con- 
centrated soups frequently repeated, and this plan may be 
followed if that already referred to does not succeed. 

The acute form of dilatation is most satisfactory to treat 
if recognized early, the chronic form most unsatisfactory as 
a rule, for if the dilatation is due to an actual obstruction, 
although the diet may be modified as already explained to 
meet varying degrees of stenosis, the time eventually comes 
in practically all cases when the case becomes a surgical 
condition (if indeed it is not from the beginning), and an 
operation imperative. 

GASTRIC NEUROSES. 

The forms which gastric neuroses can take are many, but 
they group themselves naturally about disturbances in — 
I, secretion; II, sensation, and III, motility. 

The neuroses play a much smaller role in diagnosis than 
they formerly did, since we have come to know that many 
conditions previously considered neuroses have a definite 
pathological basis, that, for example, Reichman's disease or 
continuous gastric secretion can no longer be placed with the 
neuroses but is due to some form of chronic irritation along 
the gastro-intestinal canal, and is perhaps most frequently 



380 DIET IN DISEASES OF THE STOMACH 

associated with chronic gastric or duodenal ulcer. So too, 
if one considers the so-called neuroses of sensation we find it 
necessary to recast most of these diagnoses and the persistent 
gastralgia formerly classed as a neurosis is now known to 
betoken real trouble in practically every instance, due to 
chronic ulcer, appendicitis or gall-bladder disease in most 
instances. So it goes throughout the entire list; neverthe- 
less there are some real digestive neuroses left belonging to 
all three classes which require attention, medically and 
dietetically. 

Secretory Neuroses. — By far the greatest number of these 
cases have an excess of secretion, particularly of hydro- 
chloric acid. This gives rise to nervous hyperchlorhydria 
with its attendant symptoms of acid eructation, belching, 
constipation, etc., all coming on at times of stress when the 
nervous system is overirritated, as for example in students 
preparing for examination, young speakers and actors. 
Even in these cases if there is continued repetition of the 
symptoms one must be on the lookout for a pathological 
basis. The diet here should be that described for hyperchlor- 
hydria, avoidance of all irritants must be insisted upon, 
such as: chemical, e. g., acids, alcohol and condiments; 
mechanical, e. g., seeds or hard substances; thermal, e. g., 
hot or iced drinks or foods ; and as well, food should be simply 
prepared, eaten slowly at regular intervals and with full 
attention to proper methods of eating. The general hygiene 
of the nervous system should also receive attention (see 
Hyperchlorhydria). Excessive secretion may at times be 
purely nervous, but continuous secretion is usually of patho- 
logical significance. 

In other cases the neurosis takes the form of a hypoacidity 
even to an achylia gastrica which has been supposed at times 
to be of nervous origin, although probably even in many of 
these an anatomical basis may be found. The diet for this 
should be that advised for hyposecretion or achylia gastrica 
(see p. 343) and in general should be stimulating but not 
irritating. 

Neuroses of Sensation. — All sorts of morbid gastric sensa- 
tions may be felt by the neurasthenic, ranging from merely a 
sense of uneasiness or fulness to actual pain, the latter, how- 
ever, as already stated if persistent or recurring is almost 
always due to some pathological state of the digestive tube 
itself and is not a neurosis. The treatment here should be 
of course, largely along neurological lines, the diet must be 
full, simple and nutritious and if the symptoms occur in 
patients (especially women) who are thin, and so to speak 



GASTRIC TEST MEALS 381 

"on wires" nervously, they should be put to bed and given 
the rest cure regimen, such as that devised by Wier Mitchell 
or some modification of it. The digestive symptoms usually 
disappear within the first week of this routine. 

Motor Neuroses. — Many of the abnormal sensations in- 
cluded under this last group are due to a nervously disturbed 
gastro-intestinal musculature, giving rise to peristaltic un- 
rest which in a normal state passes unnoticed, but which 
loom large to the nervous person. Another and familiar 
form of motor disturbance is seen in nervous vomiting which 
is often so difficult to control. All these forms of motor 
neuroses must be treated first from a general hygienic and 
neurological point of view by hydrotherapy, suggestion, etc., 
diet may often be ignored and in many instances if we can gain 
the patient's confidence they can often be told to eat anything 
they want and it will many times be found that such seeming 
indulgence works wonderfully well, anything within reason 
being digested. At other times one must treat these cases 
as one does a stomach which is irritable from some patho- 
logical cause, for often a digestive organ that has been mis- 
behaving for a long time develops a secondary irritation 
which is real and must be definitely treated by a diet that is 
useful in any irritable stomach, e. g., fluids, as milk and Vichy 
or buttermilk and Vichy, egg albumen in cracked ice and 
water, iced bouillon, iced malted milk, gruels, thin soft 
solids, cereals, custards, blanc mange, soft eggs, cream toast, 
back to solids with white meat of chicken, baked farina, 
vermicelli, noodles and by degrees to a normal dietary. 

GASTRIC TEST MEALS. 

Ewald-Boas Test Breakfast. — Water, 400 c.c. (13 oz.) ; 
bread or roll, 40 gm. (1^3 oz.). Given on an empty stomach. 
Expressed by aspiration one hour later. 

Ewald Test Dinner. — Chopped meat 165 gm. (6 oz.); stale 
bread, 35 gm. (1 oz.) ; butter. Aspirate three hours after- 
ward. 

Test Meal of Germain, See. — Chopped meat, 100 to 150 
gm. (3 y% to 5 oz.) ; white bread, 60 to 80 gm. (2 to 2% oz.) ; 
water, 300 c.c. (10 oz.). Examine contents two hours later. 

ReigeVs Test Dinner. — Meat broth, 400 c.c. (13 oz.); beef- 
steak, 150 to 200 gm. (5 to 7 oz.); mashed potato, 50 gm. 
{1% oz.); roll, 35 gm. (1 oz.). Should be aspirated four 
hours later. 

Klemperefs Test Meal. — Milk, 500 c.c. (1 pt.) ; 2 rolls 
(70 gm.). Give on empty stomach and aspirate two hours 
later. 



382 DIET IN DISEASES OF THE STOMACH 

Boas {Non-lactic Acid-containing) Test Meal. — Oneoz. 
(30 gm.) rolled oats boiled in 1 pt. (500 c.c.) water; salt q. s., 
or 2 shredded wheat biscuits with 300 c.c. (10 oz.) water. 
To use when testing for lactic acid the stomach should be 
washed out the night before. 

Salzers Double Test Meal. — Beef, 40 gm. (i}4 oz.), scraped 
and broiled; milk, 250 c.c. (8 oz.) ; boiled rice, 50 gm. {1% 
oz.) ; 1 soft-boiled egg. Four hours later give Ewald-Boas 
test meal and remove one hour afterward. 

The Ewald meal may be used or one pint of gruel made 
of strained oatmeal or any cereal just thin enough to be 
aspirated through the small tube ordinarily used. A sample 
of the gastric contents is aspirated and tested chemically 
y£, 1, 1/4,2 and 2)4 hours after taking the meal. 

GASTRIC MOTOR MEALS. 

Von Luebe. — Soup, 400 c.c. (13 oz.); beef, 200 gm. (6% 
oz.); bread, 50 gm. (1% oz.); water, 200 c.c. (6% oz.). 
If at the end of six hours gastric lavage fails to show a resi- 
due, the motor power of the stomach is normal. 

Boas. — If two hours after an Ewald-Boas test meal the 
stomach is empty by lavage, there is normal motor power. 

Hausman 1 s Stagnation Test Meal. — Four tablespoonfuls of 
boiled rice and a glass of water are given at 9 P. m. (a little 
sugar and milk may be taken on the rice). If at 9 A. M. next 
morning fasting, lavage fails to show macroscopic or micro- 
scopic rice residue, there is no stagnation. (A drop of Lugol's 
solution stains any starch granules blue so that they are 
easily seen.) 

Test Supper. — For supper, meat, bread, butter and water 
or two cups of tea. Lavage in the morning following should 
fail to show any residue in a normal stomach. 

Water Test for Acidity. 1 — Carlson, Orr, Hanke, Brackman 
and Rehfuss all observed that the taking of water stimulated 
gastric secretion, producing an acidity that was about 100 
in less than twenty minutes after stimulation. They found 
that in ten to twenty minutes 500 c.c. (10 oz.) of water would 
leave the stomach (? Ed.) and also that after drinking 50 c.c. 
(1% oz.) of water as much as 225 c.c. (7 oz.) of gastric juice 
could be obtained. 

Austin's meal directions are as follows, partially based on 
the foregoing: Previous evening the patient takes a meal of 
meat, potato, bread, butter, rice and raisins and presents 
himself the next morning for examination, fasting. Then 

1 Austin: Boston Med. and Surg. Jour., 1915, clxxii, 857. 



DIET IN DISEASES OF THE STOMACH 383 

350 c.c. (12 oz.) of water are given and removed by the 
stomach-tube in twenty minutes. Austin found the total 
acid values much lower than those already quoted, varying 
from 19 to 31. 

Intestinal Motor Meal {Schmidt- Strassburger). — With the 
meal two capsules, each containing 0.5 gm. (7^ gr.) of char- 
coal are given to mark the meal, then the following: finely 
cut meat, 80 gm. (2% oz.) ; mashed potato, 200 gm. (6% 
oz.); eggs (2); butter, 40 gm. (ij£ oz.) ; oatmeal gruel made 
with milk, 1500 c.c. (3 pt.); clear soup, 250 c.c. (8 oz.;) very 
dry toast or zweiback, 100 gm. (3^ oz.). In health it is 
said this should pass through the intestine in fifteen to twenty- 
five hours. In diarrhea due to colitis, in ten to fifteen hours. 
In enterocolitis with diarrhea, in three to five hours (Strauss). 

For further intestinal test diet see Schmidt, Intestinal 
Diet (p. 387). 



CHAPTER XXI. 
DIET IN DISEASES OF THE INTESTINES. 

In diseases of the intestines, no less than in gastric disturb- 
ances, diet plays a most important role, not alone from the 
therapeutic standpoint but from that of prevention as well. 
Another interesting development of more recent years is 
the effect of various foods on the intestinal flora and the 
possibility of changing this at will by the institution of a 
definite diet. 

One group of bacteria designated as putrefactive thrive 
particularly in the large intestine. 1 A second group, the 
fermentation bacteria, may also thrive and where they do 
acid conditions are likely to arise which inhibit the growth 
of the putrefactive organisms. According to Hester and 
Kendall 2 the absence of carbohydrate in the diet allows the 
proteolytic bacteria to predominate, — this is told by the 
fecal discharges, as well as the finding of indican and its 
congeners in the urine. 

Torry 3 found in typhoid cases fed with an unusual quantity 
of lactose that the ordinary type of flora was changed to one 
largely cominated by the bacillus acidophilus. Lactose and 
dextrine added to a meat and rice diet caused a marked 
development of aciduric bacteria of the bacillus acodophilus 
type almost to the suppression of the proteolytic type. Glu- 
cose did not have this effect. Starchy food also had the 
tendency to eliminate the putrefactive bacteria. Protein 
foods failed to produce a stereotyped change. Milk for 
example was less likely to give rise to putrefaction than did 
meat. Torrey also found that vegetable protein was less 
likely to encourage the putrefactive bacteria than animal 
protein. Fats seemed to lack a determining influence. 

From all this it can be readily seen that the dieting of 
some cases of chronic intestinal disturbances must be founded 
on carefully collected data in which the examination of the 
stools, not only for gross and chemical changes but for bac- 
terial divergences from the normal is made. 

Then too, certain cases of diarrhea originate from ab- 
normalities in the gastric or pancreatic secretions, which 
must be tested if one is to come to a rational etiological diag- 
nosis. Thus one sees cases diagnosed as chronic enteritis 

^d. Jour. Am. Men. Assn. May 10, 1919, page 1370. 
2 Jour. Biol. Chem, 1910, vii, 203. 
3 Jour. Inf. Dis., 1915, xvi, 72. 

384 



Acute enteritis 385 

in which the intestine is practically normal except for slight 
secondary inflammatory changes and the diarrhea is caused 
by a failure of gastric secretion, the so-called gastrogenic 
diarrhea already referred to. In the intestine too, we have 
the most marked examples of functional neurosis, due to 
lack of nervous stability, resulting in diarrhea of various 
types, as well as constipation. 

ACUTE ENTERITIS. 

Enteritis, or inflammation of the small intestine, is of fre- 
quent occurrence and one has only to glance over the etiologi- 
cal factors to realize how many conditions there are that may 
give rise to it. Among these causes may be mentioned die- 
tary indiscretions, unhygienic surroundings, frequent ex- 
posure to sudden atmospheric changes, irritants, as some 
acids, mercury, arsenic, cantharides, copper, tartar emetic, 
garlic, alcohol. Blood irritants, seen in uremic conditions; 
mechanical irritants; bacillary infections of the intestinal 
tract; parasites; the exanthemata; chronic constipation; 
intestinal obstruction ; disturbances of circulation ; drinking 
ice-water to excess, 1 etc. 

The inflammation may affect any part of the small bowel, 
so that we may have a duodenitis (distinguishable from the 
other locations on account of the frequency of a complica- 
ing jaundice); jejunitis and ileitis. Aside from the duo- 
denitis, of course it is impossible clinically to distinguish 
which part of the bowel is involved. 

Conheim 2 divides enteritis into: 

I.. Mild enteritis without diarrhea, but with numerous 
symptoms, such as meteorism, abdominal pains, flatulence 
and loss of strength. 

2. Moderately severe enteritis with much intestinal fer- 
mentation and frequent diarrhea. 

3. Severe cases with persistent diarrhea. 

The dietetic treatment of the acute cases resolves itself 
into a negative and positive phase. Under the former we 
are content during the acute onset to withhold all food for 
twenty-four hours or possibly longer, giving only water and 
a good cathartic to relieve the bowels of any offending matter; 
for in spite of the diarrhea which is present in the moderate 
or severe cases, nature usually needs assistance in this. 

This is particularly true in the severe acute type, ordinarily 
known as cholera morbus. After the preliminary period of 

x Gant: Diarrhea Inflammation and Parasitic Intestinal Diseases, p. 176. 
2 Forchheimer : Therapeutics, iii, 197. 

25 



386 DIET IN DISEASES OF THE INTESTINES 

starvation one may begin feeding thin gruels, albumin water, 
rice, or toast, water and weak tea. Milk is best left out of 
the diet at the outset, for it is seldom properly digested while 
peristalsis is so active and even in the late stages it fails to 
agree as well as some of the carbohydrate or other protein 
foods. Some cases, however, do well on boiled milk, for the 
boiling causes it to respond to the gastric enzymes in a fine 
flocculent curd ; in still others it can be given advantageously 
raw and over long periods. When the. disease reaches the 
subacute stage in mild cases, one may feed most of the soft 
foods, such as eggs, soft meats, sweetbreads, stewed or boiled 
chicken, creamed fresh cod, halibut and whitefish. If there 
is not much flatulence one may give the fine cereals well 
cooked, farina, cream of wheat, rice, wheatena, malted 
breakfast food with a little butter and salt. These cereals 
are not good when there is a tendency to or actual excessive 
carbohydrate fermentation in the intestine, as shown by 
explosive acid stools and an active formation of CO 2 in the 
fermentation tube. Later on soft-cooked or puree vegetables 
put through a colander are allowable, such as spinach, peas, 
potatoes, carrots and celery, but as a rule vegetables should 
be left out of the diet on account of their laxative effect. 
Soft custards, blanc mange, farina or rice pudding and gela- 
tin desserts are allowable in the mild or subacute cases. 

There are very definite foods which should not be eaten at 
any time in any type of this trouble, such as coarse or irritat- 
ing foods, those which- ferment easily or putrify readily, and 
all the foods given must be soft and free from indigestible 
particles. Not much sugar should be given. Wines, beer 
or champagne are not allowed with the exception that in the 
later stages a little diluted claret or sherry may be permitted. 

Among the vegetables under the ban are cauliflower, tur- 
nips, cabbage, radishes, onions, tomatoes, celery root, oyster 
plant and Brussels sprouts. No fruit may be taken, nor 
cake, rich jellies or other sweets. Rich cheese, high meat or 
game are also forbidden. 

In general the milder the case, the less strict need the diet 
be and vice versa. 

CHRONIC ENTERITIS. 

This may be chronic from the start or may be the remains 
of an acute attack, the etiology being the same as that of the 
acute cases, but acting more slowly, or it may be an accom- 
paniment of other diseases of the bowels as, e. g., carcinoma, 
intestinal obstruction, fecal impaction, etc. 1 In the chronic 
forms of enteritis, it is particularly satisfactory to make a 

1 Stengel, in Osier's Mod. Med., 1914, 2d ed. 



CHRONIC ENTERITIS 



387 



definite test of the patient's digestion as affecting the proteins, 
fats and carbohydrates, after which it is possible to plan a 
rational diet suited to that individual's needs. 

This is arrived at most certainly by placing the patient 
on a Schmidt test diet, which is as follows: 

Schmidt Test Diet. — In the morning, 0.5 liter (16 oz.) 
milk, or, if milk does not agree, 0.5 liter (16 oz.) cocoa, pre- 
pared from 20 gm. {% oz.) cocoa powder, 10 gm. (J/£ oz.); 
sugar, 400 c.,c. (13 oz.) water and 100 c.c. (3^ oz.) milk. 

In the forenoon. 0.5 liter (16 oz.) oatmeal gruel, made from 
40 gm. {\\i oz.) oatmeal, 10 gm. {}/% oz.) butter, 200 c.c. 
(6>2 oz.) milk, 300 c.c. (10 oz.) water; 1 egg strained. 

At noon, 125 gm. (4 oz.) chopped beef (raw weight), broiled 
rare with 20 gm. (% oz.) of butter, so that the interior will 
still remain raw. To this add 250 gm. (8 oz.) potato broth 
made of 190 gm. (6 J 
oz.) milk, and 10 gm. (J 

In the afternoon as in the morning 

In the evening as in the forenoon 



3 oz.) mashed potatoes, 100 c.c. (3^ 
'3 oz.) butter. 



This diet cons 

Milk , 

Zwieback 

Eggs . 

Butter 

Beef . 

Potatoes 

Oatmeal (gruel) 



sts of 



1.5 liters (iKqt.) 

100. o gm. (3>£ oz.) 

2.0 

50.0 gm. (1 [") 

125.0 gm. (4 " ) 

190.0 gm. {6}4 " ) 

80.0 gm. (2% " ) 



This contains protein, 102 gm. (3^$ oz.); fat, in gm. 
(4 oz.); carbohydrates, 191 gm. (63^ oz.); calories, 2234. 

In order to carry this diet out most satisfactorily it is best 
to give it for a couple of days and then give two capsules each 
containing 10 grains of charcoal. This is given again at the 
end of the test period of two, three or four davs as may have 
been decided and the stools and urine saved accurately for 
the period which is marked at its beginning and end by the 
charcoal. 

The result of the examination of the feces will show whether 
the stools contain undigested food, meat fibers connective 
tissue, free starch, fat drops, fatty acid crystals, soaps or 
parasites. At the same time the pancreatic ferments may 
be tested for and the presence of carbohydrate and protein 
fermentation disclosed if it is present. Also the prevailing 
bacterial growth whether Gram-negative (normal) or Gram- 
positive. 

It will be found that a good many patients, particularly 
women and especially so if both their stomach and intestinal 
digestion are poor, cannot take the full Schmidt diet, the 



388 DIET IN DISEASES OF THE INTESTINES 



quantity is too great. In such instances the test diet as 
modified by the author will be found very serviceable as 
containing the proper proportions of food elements and of 
sufficient caloric value. 

Modified Schmidt Diet. 



Oatmeal . . 165 gm. 
Rice ... 90 " 
Milk . . . 1500 c.c. 
Butter . . 40 gm. 
Bread . . 120 gm. 
Chopped meat 65 gm. 


(5# oz 

(3 " 
(5o ' 
(iM ' 

(4 ' 
(2 ' 


Protein. 

•) 4-4 
) 2.4 

) 49-5 
) 0.6 

) 131 
) 17- 1 




Fat. 
0.8 
0.8 
60.0 
34-0 
2.4 
4-7 


Carbohydrate. 
18.2 
21.0 
67-5 

80.0 


Calories 
100 
100 

1080 

318 

400 
100 






87.1 gm. 


[02. 7 gm. 186.7 gm. 


2088 


Breakfast. 
Oatmeal, 165 gm. (5^ oz.) 
Milk, 250 c.c. (3 " ) 
Bread 40 gm. (i}4 ") 
Butter, 15 " ( y 2 " ) 


Meat, 
Bread, 
Milk, 
Butter 


Dinner. 
65 gm. 
40 " 
250 C.C. 
, 10 gm. 


(1 oz.) 

dVs ") 

(8 ") 

(H ") 


Supper. 
Rice, 90 gm 
Bread, 40 " 
Butter, 15 " 
Milk, 250 c.c. 


(3 
dH 
( X 

(8 



At 10, 3, and 9 o'clock, 250 c.c. milk. 



oz.) 



"■) 



Having determined the digestive capacity of the pan- 
creatic or intestinal enzymes by the use of the Schmidt diet, 
the task still remains of constructing a suitable diet for these 
patients. Chronic enteritis is not a condition that shows 
rapid improvement and weeks and months must often elapse 
before anything like satisfactory progress can be expected. 
On this account patients must be warned and told to expect 
slow changes, as otherwise they are quite 'sure to become 
discouraged and blame their medical attendant for failure 
to improve rapidly. When the stools show undigested food, 
whether diarrhea is present or not, the diet is not what it 
should be and the first constant aim must be to get a diet 
that can be digested, showing a normally smooth stool, even 
though its consistence may be too soft or fluid. This, of 
course, can only be done by painstaking changes with con- 
stant stool inspection to check up the condition of digestion. 

It is usually a good plan in starting the dietary treatment 
of these cases to begin with a liquid or semiliquid diet. Just 
which combination of foods will fit the individual case can 
only be determined by trial, but an ordinarily successful 
plan is to feed them every two hours with gruel, malted milk, 
cocoa and soft egg alternately. Some cases digest boiled 
milk well and it is often deserving of a trial. If it is not 
digested as shown by curds and more active diarrhea then 
it should be omitted, even in the cocoa which should then be 
made with water. After a few days of this rigid diet, one 
may begin to add one extra at a time, preferably with every 
other feeding, i. e. y every four hours. These extras may be 



ACUTE COLITIS 389 

in the form of fine cereal, farina, cream of wheat, wheatena, 
eaten with a little butter and salt or with a little malted 
milk over them. Then dry toast with or without butter is 
added. After which one may keep on gradually increasing 
the foods to boiled rice, macaroni, dry cheese, cream cheese, 
toasted crackers. By this time, it is well to lengthen the 
feeding interval to three or four hours. The character of 
the diet can be changed as rapidly as improvement in symp- 
toms comes, adding next finely minced chicken and sweet- 
breads, lamb, boiled fresh white-meated fish. Desserts 
made of gelatin, egg or farinaceous puddings, later cream 
desserts, all made with the minimum amount of sugar. All 
vegetables should be left out of the diet for a long time, but 
when taken they should be thoroughly cooked, soft, and put 
through a colander, or in the form of a puree. Fruits should 
be added last and then only well-cooked, soft fruits, such as 
baked apple (without the skin), apple sauce, etc. Of course, 
fruit should not be given until the stools are of nor- 
mal consistence and well digested and it will be probably 
weeks or months after starting treatment before it can be 
given. 

ACUTE COLITIS OR ACUTE DYSENTERY. 

Acute dysentery is caused by a variety of factors, bacillary, 
protozoon and constitutional, and results in an acutely in- 
flamed colon mucous membrane which may or may not go 
on to ulceration, depending on the form and severity of the 
exciting cause. It is often found as a part of an infection 
involving the small intestine as an enterocolitis, or it occurs 
alone. 

When it occurs as part of an infection higher up, the die- 
tary treatment is in accordance with the needs of the small 
intestine, when it occurs alone it is often very sudden and 
severe in its onset and requires great care in treatment. 
After a complete emptying of the bowel by catharsis, it is a 
good plan to withhold food for twenty-four hours in order 
to quiet the peristalsis, using opium or other antiperistaltic 
agent. When feedings are begun they should be liquid and 
at first largely protein, as whey, albumin water and clear 
soups, then gruel made of oatmeal, farina or wheat cereals 
or koumyss: sweet milk should not be given, as it tends to 
increase the diarrhea, although this is less marked if the 
milk is boiled. Later scraped meat, dry toast, well cooked, 
fine cereals, soft-boiled or poached eggs, macaroni, well- 
boiled rice, weak tea or a little dilute whiskey or 'claret form 



390 DIET IN DISEASES OF THE INTESTINES 

the bulk of the diet. When the acute symptoms subside 
the patients are either well or the disease goes on into the 
chronic stage. In the acute stage fruit and vegetables are 
to be avoided. In the severe forms, withholding food for 
several days is often a good plan. 

CHRONIC COLITIS. 

Whatever the origin of the colitis or whatever pathological 
form it takes, there are certain dietary conditions which 
must be taken into consideration and met in all cases. 

1. That the diet must be made up of easily digestible 
foods. 

2. That the foods must not be stimulating to peristalsis. 

3. That all food must be finely subdivided, soft and with 
as little digestive residue as possible. 

4 The quantity of food must be sufficient for complete 
nutrition in nitrogen and caloric content. 

As to the first point the foods particularly suitable are : — - 
clear, cream or puree soups, white-meated fish; (other richer 
forms later if they agree wth gastric digestion) ; soft part of 
oysters, beef, mutton, chicken, sweetbreads, eggs, fine cereals, 
farina, cream of wheat, malted breakfast food, wheatena, 
tea, coffee, cocoa made with water, butter, toast, stale bread, 
roll, puree of vegetables such as potato, lima beans, peas, 
spinach, stewed celery, baked Hubbard squash. (In many 
cases no green vegetables can be taken at all on account of 
increased peristalsis.) Farinaceous puddings, gelatin des- 
serts, egg desserts. (For food stimulating to peristalsis see 
Section on Diarrhea.) In general it may be said that fruits, 
coarse vegetables (in some cases any vegetables), very sweet 
foods, much fat food, are all stimulating and must be avoided. 
Milk is also in this class for most patients, although occa 
sionally a patient can take it boiled or diluted with gruels. 
Sometimes koumyss will be better digested than plain milk. 
White wine, beer, ale and champagne are contra-indicated. 

That patients should receive sufficient food for nutritional 
uses is self-evident, but it is not by any means easy to nour- 
ish many of these patients completely, as there is often much 
anorexia, and if pain is also present, it is still more difficult 
to feed them. 

In the long-standing cases, particularly those due to ulcer- 
ative colitis, malnutrition is more or less the rule and some 
patients lose as much as half their body weight, it being 
impossible to get them to take a sufficient supply, and the 
ingenuity of the physician is put to a severe test. In these 



MEMBRANOUS COLITIS 391 

long-standing and severe cases the use of artificial food 
materials is often useful (see Artificial Foods) to fortify 
soups and gruels. 

MEMBRANOUS COLITIS, MUCOUS COLIC OR CHRONIC 
MUCOUS COLITIS. 

It was formerly thought that these cases were in the last 
analysis of a neurotic origin, occurring only in nervous per- 
sons; and while many of the patients were nervous it was 
also observed that the disease occurred in those who were 
not at all so. Nothnagle was largely responsible for this 
general belief, but time has proven it untenable when applied 
to the cases as a class. The characteristic feature of the 
disease is the passage of mucous strips, bits, ribbons or even 
entire casts of parts of the colon and accompanied by more 
or less abdominal pain. There are two groups 1 ordinarily 
distinguished. 

i. Those with pain along the colon and a tendency to 
diarrhea, i. e., chronic mucous colitis. 

2. Those occurring in nervous persons who have chronic 
constipation and attacks of " membranous colitis" or "mu- 
cous colic." 

The diet in the first group is c o constructed as to spare the 
bowel as much irritation as possible and consists largely of 
albuminous foods together with farinaceous gruels, all coarse 
foods are excluded as well as vegetables and fruits, the rest 
of the feedings are as already described in the section on 
Enteritis or Chronic Colitis. In the second group there is 
really a catarrh of the bowel and in addition chronic constipa- 
tion. Von Noorden fastened upon the chronic constipation as 
the essential feature of the disease and by combating this was 
able to clear up the mucous stools In order to accomplish 
this he prescribed a diet with much cellulose, indigestible 
residue in skins and seeds, coarse black or rye bread, crude 
vegetables, raw or cooked, but the rougher the better, cab- 
bage, tomatoes, turnips, carrots, celery, cauliflower, Brus- 
sels sprouts, corn, etc., also large amounts of fats in the form 
of cream, butter, fat meats and oils. Cider and buttermilk 
are both good for this purpose. 

The following diet devised by Butman is recommended 
and is also good for chronic constipation generally. 

On rising a glass of cold water. 

Breakfast: Oatmeal, whole wheat or graham bread (or 
bran bread), butter, coffee, raw or cooked fruit. 
Marmalade (honey). 

1 Forchheimer, vol. iii. 



392 DIET IN DISEASES OF THE INTESTINES 

Midmorning: A glass of buttermilk or cider, or water, 
dried fruit, figs, dates or prunes. 

Luncheon: A small amount of meat, fish or other sea- 
food, two or more green vegetables, coarse bread, 
butter. Fruit. 

Midafternoon: A glass of buttermilk or cider, etc. 

Dinner: Fruit, meat or fish, two or more green vege- 
tables, coarse bread, butter (bran bread or biscuits), 
salad, dessert, preferably a fruit dessert. 

Bedtime: Same as midmorning. 
Or the diet recommended under Chronic Constipation. 

ULCERATION OF THE SMALL OR LARGE INTESTINE. 

Ulceration of the small or large bowel occurs in a variety 
of conditions, e. g., simple ulceration as in duodenal ulcer 
or as the result of typhoid fever, tuberculosis or other bac- 
terial or protozoan diseases. 

In simple or typhoid ulceration the diet has already been 
described under these headings. In tuberculous ulceration 
and that due to other bacteria, as in chronic dysentery or 
amebic dysentery, the dietary regulations are practically 
alike. The diet should be free of irritating foods, seeds, 
skins, raw vegetables or those with a rough residue, as corn, 
bran, etc. Everything should be exceedingly soft and of 
moderate bulk. When diarrhea is present one must be gov- 
erned in the selection of food by a knowledge of what foods 
are naturally laxative and avoid them, using on the contrary 
the classes of foods which have been described under Enteritis 
and Diarrheal Diseases in general. 

Laxative foods include fruit, vegetables, indigestible fats, 
sugars, game, "high" meat, malt liquors, rough substances, 
such as bran. 

INTESTINAL HEMORRHAGE. 

The diet in intestinal hemorrhage, if at all severe, should 
be regulated much as has already been described under 
Hemorrhage in Typhoid. All food by mouth should be stopped 
at once. If the hemorrhage is from a point high up in the 
intestine, as that from duodenal ulceration, not even water 
should be given for from forty-eight to seventy-two hours. 
(See Duodenal Ulcer, p. 349.) If the patient is desiccated 
it will be necessary to give warm saline by the rectal route 
within six hours of the hemorrhage, either as a continuous 
Murphy drip, or in repeated amounts of 4 to 6 ounces every 



DIARRHEA 393 

two, three or four hours. If the hemorrhage is from lower 
down, as from the ilium in typhoid, water may be begun 
within six hours, and within twelve to twenty-four hours 
one may again begin mouth feedings with broth, albumin 
water, malted milk or diluted citrated milk (i grain of 
sodium citrate to the ounce). After another six to twelve 
hours the feedings may be gradually and steadily increased 
again until full fluids are being taken. It is not necessary 
to interdict water in these cases and this may be given in 
small amounts, frequently repeated two or three hours after 
the hemorrhage. Large or very hot enemata of water should 
not be given on account of their tendency to dilate the 
abdominal vessels, which of course, increases the danger of 
hemorrhage. When the hemorrhage is from the colon, it 
is scarcely ever severe enough to cause anxiety and only in 
exceptionally large hemorrhages need one hesitate to con- 
tinue giving fluids by mouth. Of course, under this circum- 
stance no fluid should be given by rectum. 

DIARRHEA. 

As diarrhea is merely a symptom, a classification of its 
etiology would include a discussion of every condition which 
may give rise to this symptom, the treatment being often 
quite as various as the etiology. 

The Causes of Diarrhea. — In general the causes of diarrhea 
may be enumerated as follows: 

Gastrogenic. — When achylia gastrica is present this in 
some way predisposes to diarrhea, probably the lack of acid 
secretion fails to call out the pancreatic enzymes sufficiently 
to properly digest the food, and diarrhea results. 

Toxic. — In cases of chronic Bright's, diarrhea is often 
present and represents the attempt of nature to eliminate 
water, chlorides, toxic material and probably nitrogen by 
way of the intestinal mucosa, being therefore a vicarious 
diarrhea. Other varieties of toxic origin are seen in the acute 
bacterial intestinal diseases, typhoid, cholera and cholera 
morbus; ptomaine toxemia including all forms of food 
poisoning, which are almost invariably accompanied by 
diarrhea. The toxic effect of the inorganic salts must also 
be included, principally arsenic, mercury and antimony, and 
to the milder toxic infections, such as intestinal catarrh, 
acute and chronic. 

Irritative Diarrhea, which may be toxic or merely mechan- 
ical, as the eating of quantities of indigestible food such as 
corn, fruit in excess, etc., excess of gastric HC1. 



394 DIET IN DISEASES OF THE INTESTINES 

Drug Diarrhea, due to ingestion of laxative drugs which if 
taken in excessive amount or over long periods, often con- 
tinue the diarrhea after the complete elimination of the drug 
which is then probably due to a catarrhal inflammation. 
Ulcerative conditions of the gastro-intestinal tract — peptic, 
tuberculous and simple ulcer or the numerous forms of 
diarrhea due to a diseased colon. 

Nervous Diarrhea. — Many people have this difficulty in 
the face of some unusual excitement, soldiers, musicians, 
and in hysteria and are all due to vasomotor dilatation in an 
unstable nervous system, causing the so-called "sweating" 
of the intestine. Under this heading the diarrhea of hyper- 
thyroidism may belong, although this is quite as likely to be 
due to the general toxemia seen in these cases. Reflex 
diarrhea is also of nervous origin. 

Habit Diarrhea. — Some persons normally have several 
more or less watery stools a day or they may have a morning 
diarrhea, often due to catarrh, however. 

Diarrhea due to Food Idiosyncrasy. — In these cases some 
one article of food may habitually excite a diarrhea quite 
apart from any known toxic or mechanical effect, although it 
is probably of toxic origin in the last analysis. 

Diarrhea of Pancreatic Origin. — Where the ferments are 
deficient, as the well-known fatty diarrhea. 

Diarrhea occurring as secondary to periods of fecal im- 
paction with a tunneling of the fecal mass, or alternating 
with severe constipation. 

With all these forms of diarrhea the etiology gives the 
clue to the dietetic treatment and an accurate diagnosis is 
always essential to a satisfactory and intelligent ordering of 
foods. 

It is unfortunately not possible to find in every cases the 
actual cause, so that the clinician is not infrequently called 
upon to prescribe a diet for diarrhea in which the etiology is 
obscure and eludes the most painstaking investigation. The 
underlying principles are much the same in ordering diets 
for almost all the forms of diarrhea and may be described as 
follows : 

Dietary Regulations. — The diet should be non-irrritating, 
easily digested, not a stimulant of peristalsis, free from taint 
of putrefaction, finely comminuted and should include as 
many articles of food that are naturally astringent as pos- 
sible, and not apt to ferment. 

In acute diarrhea from any cause a period of starvation 
following an intestinal purge is the best dietetic routine, 
allowing fresh but not cold water in abundance. When the 



DIARRHEA 395 

appetite begins to demand food, clear broth, beef tea, cereal 
gruels, dry toast and tea are best for a day or two, gradually 
extending the list from foods which are allowed in chronic 
diarrhea. 

Foods to Avoid in Chronic Diarrhea. — Very fatty foods, 
except a moderate amount of butter. Raw milk and cream. 
Green vegetables of all sorts. Boiled potato. Corn is 
especially irritant. Fruit in all forms is forbidden, whether 
stewed or fresh. Salads, nuts, pickles, condiments. Salt 
meat or salt fish. Smoked meats or fish. Goose, duck, 
pork as too fat. Sweets, cake, pie, candy, and preserves. 
Cream or milk desserts. Sweet wine, beer and ale. 

Foods Recommended in Diarrhea. — Clear soups, white- 
meated fish (not fatty), e. g., cod, halibut, bass. Chicken, 
mutton or lamb, scraped beef, soft part of oysters. Guinea 
hen. Soft eggs. Rice, macaroni, noodles. Baked potato 
may agree. Cereals except oatmeal or Pettijohn. Stale 
bread or dry toast, crust of roll. Toasted crackers. Cream, 
Edam, Canadian cheese. Farinaceous puddings made with 
little sugar, preferably baked. Calf's foot or wine jelly. 
Tea, clear coffee (in some cases this is laxative), water, claret, 
Burgundy. A little diluted whiskey or brandy. In some 
instances malted milk is well tolerated, while in others it is 
laxative. In a few cases it is possible to give boiled milk, 
but for the most part milk in any form is very badly tolerated 
causing an increase in the diarrhea with the passage of un- 
digested curds. 

Foods Allowed in Certain Cases. — The use of malted milk 
or cereal is useful unless it proves laxative. Crisp baccn, 
turkey, koumyss, zoolak, buttermilk. Thoroughly stewed 
celery, baked Hubbard squash, creamed spinach, tender 
boiled peas or lima beans mashed through a colander, re- 
moving the skins. 

Chronic Diarrhea — Cohnheim s Diet List {American Modifi- 
cation). 

7.00 a.m. Mineral water, 75 to 150 c.c. {2% to 5 oz.), 
taken hot on rising. The choice of water 
will depend on gastric secretions, with hypo- 
acidity or achylia, sodium chloride and 
alkaline waters are best. At home 10 
grains of salt and 10 of bicarbonate of soda 
may be added, to the allowance of hot water. 
7.30 a.m. Philip's digestible cocoa (2 teaspoonfuls to a 
cup) made with water. Toasted white 
bread and butter. 
10.30 A.M. Fine cereal, cream of wheat or farina or malted 
breakfast food, one soft-boiled egg or scraped 
meat or lamb chop cut fine. 



396 DIET IN DISEASES OF THE INTESTINES 

I. oo p.m. Broth with macaroni, vermicelli or noodles. 
In mild cases vegetable purees. One glass 
of claret. 
4.00 P.M. Same as 7.30 a.m. 
6.00 p.m. Mineral water as in early morning. 
7.00 to 8.00 p.m. Tea with claret. Toast, butter and a 
little cold chicken. 
. 9.00 to 10.00 p.m. A cup of hot peppermint tea or chamo- 
mile tea. If the case is mild and 
the stools soft rather than liquid, 
some soft carrots, fillet of sole or 
baked fish is allowed. 
Absolutely Forbidden Articles. — Cold drinks, all rough or 
coarse vegetables, such as cabbage, potatoes, cheese, sweets, 
coffee. All legumes unless served in soups; goose, duck, fat 
fish as salmon, mackerel, blue fish, meat fats, gravies, raw 
fruits. 

INTESTINAL NEUROSES. 

These follow much the same classification as the gastric 
neuroses except that the intestinal pain of a purely nervous 
origin is rare and as a diagnosis should only be made after a 
careful process of exclusion and even then with reservation. 
The diet in these intestinal cases is much on the same lines 
as that recommended for definite intestinal pathological 
states which symptomatically they often so closely simulate, 
e. g., in nervous constipation. Besides the general tonic 
treatment of the nervous' system, the diet should be that 
recommended for chronic constipation with a large percen- 
tage of roughage in the form of fruits, vegetables and bran. 
With the opposite condition, namely, that of a nervous 
diarrhea, a diet such as that advised for chronic diarrhea is 
advisable (p. 394) . On the other hand, one sees not a few cases 
of a type of nervous diarrhea which present a characteristic 
picture of an undernourished, anemic, worried, irritable indi- 
vidual, man or woman, who gives a history of a diarrhea of 
month's or years' standing, from whom the history is ob- 
tained that little by little they have curtailed their diet with 
the idea that first one thing, then another disagrees and 
causes the diarrhea, until they are living on perhaps only 
three or four articles of food with an entirely inadequate 
number of calories. The stools are more or less numerous, 
liquid or semiliquid which on analysis show no other abnor- 
mal characteristic than possibly some little mucus and a few 
leukocytes. If one is sure of one's ground in dealing with 
these people and can reassure them and gain their confidence 



Chronic constipation 39? 

it is usually possible to begin feeding them liberally at once 
and a good meal of finely cut tenderloin, baked potato or 
rice, green peas and a simple dessert will do more to restore 
confidence than anything else. The character of the stool 
may not change at once, but will usually return to normal 
within a few days and the diet can then be rapidly increased 
to a general mixed one with full confidence that it will be 
satisfactorily digested. 

The anemia should also be treated and a general course of 
sensible hygiene insisted upon. 

CHRONIC CONSTIPATION. 

If an aboriginal text-book on medicine should be found, it 
would probably be noted that there was no chapter on 
chronic constipation, this being a disease of modern life, a 
product of inactivity and a non-stimulating diet. The 
causes of constipation are numerous, some predisposing, 
some direct. Faulty habits of eating are most largely re- 
sponsible and a diet with little residue from cellulose will be 
very apt to result in constipation. Any condition which 
tends to the weakening of the voluntary or involuntary 
muscles will also tend to produce or exaggerate a tendency 
to constipation, such as illnesses of all kinds, lazy habits of 
exercise and irregularity in attempted evacuation, all have 
much to do with it. Chronic constitutional diseases pro- 
ducing a congestion of the abdominal organs will result in 
constipation. 

Varieties of Constipation. — The cases divide themselves 
into: 

1. Functional, either (a) atonic or (b) spastic. 

2. Organic from mechanical obstruction of the lumen of 
the gut, from within or without. 

Of all fornis, the atonic comprises most of the cases, 
possibly 90 per cent., and is due to a lazy or inactive bowel. 
The spastic variety is the direct opposite of this, in that it 
occurs as a product of overstimulation of the intestinal nerve- 
endings, giving rise to spastic contraction of the bowel and 
pain. The form of constipation due to mechanical obstruc- 
tion speaks for itself and is of only minor interest from a 
dietetic point of view. 

In the atonic constipation, every means possible must be 
used to awaken the bowel by mechanical stimulation, as by 
massage, exercise of the abdominal muscles and general body 
exercise, calisthenics or out-of-door work. 

In the selection of a diet the two important facts to be 
remembered are that the food must be as coarse and rough 



398 DIET IN DISEASES OF THE INTESTINES 

as possible, and that all sorts of fats are very valuable in pro- 
moting ease of evacuation. In many or most of the patients 
suffering from chronic constipation, the stools are of small 
bulk and the more severe the constipation the smaller the 
bulk of the stool, as the sluggishness gives an extra amount 
of time for the further and more complete disintegration and 
absorption of the foods. In other words, digestion and ab- 
sorption are often at their highest in chronic constipation, 
and if there was not sometimes absorption of other things 
besides the food, such as various digestive by-products and 
the products of bacterial putrefaction, chronic constipation 
would not be so undesirable. As it is, the condition is not 
ordinarily a favorable one for health or well-being; although 
there are many cases who do not have a movement of the 
bowels more often than once or twice a week, yet who seem 
to keep in perfect health and vigor. 

Taking food into the stomach at once excites not only 
peristalsis of the stomach but also of the bowels and parti- 
cularly of the caput coli, so that there is good physiological 
reason for the desire to defecate shortly after a meal and 
particularly after breakfast, which should be the preferable 
time for evacuation. Peristalsis is especially " stimulated 
by indigestible meat residue, vegetable fiber, cellulose, sugar 
and organic acids. Peptones stimulate it feebly, oils more 
strongly, and gases in especially CH 4 and SH 2 even more 
powerfully." 1 

Atonic Constipation. — Since in this condition the bowel 
needs stimulation one must give a coarse diet with a large 
residue much as has been recommended for "membranous 
colitis," following von Noorden's suggestion and copying 
artificially, so far as one can, the diet that is eaten by semi- 
civilized or wholly barbarous people. This should include 
much uncooked food in the form of vegetables, nuts and 
fruits of all sorts. The bread eaten should be whole wheat, 
rye, gluten or bran bread, to which nuts and raisins can be 
added. 

Vegetables. — All vegetables are good, raw celery and cold- 
slaw or cooked cauliflower, turnips, asparagus, carrots, par- 
snips, salsify or oyster plant are especially good. Jersusalem 
artichokes, raw or cooked celery, squash, either the summer 
variety or Hubbard squash, the latter preferably baked; all 
beans and all vegetable and fruit salads. A good rule for 
these patients is to help themselves to a double portion of 
vegetables. 

1 Tibbies: Food in Health and Disease, p. 349. 



CHRONIC CONSTIPATION 399 

Meat. — Fat meats are best, unless it is important to keep 
down the weight. 

Eggs and fish are also allowed. 
Cheese, except cream cheese, is forbidden. 
Fruits, especially those with much residue, pears, melons, 
apple (a raw apple at bedtime often being very serviceable). 
Oranges and grapefruit, if the section divisions are also 
eaten, particularly in oranges. All berries except black- 
berries, which are rather constipating. Dried fruit of all 
sorts, figs, pulled or stewed, dates and raisins and all nuts. 
Desserts. — Fruit desserts or puddings, blanc mange, made 
with prunes, figs, raisins or fresh fruits. Other desserts are 
allowed, but are less stimulating. 

Salad. — All kinds. The coarser, the better. Those made 
of fruit and vegetables are particularly good, as apples and 
celery, alligator pear or any other fruit salad with lettuce. 
Fats. — Fats of all sorts, animal, vegetable and mineral are 
useful. The mineral oils introduced by Lane for intestinal 
stasis are often very beneficial. 

Each case of atonic constipation must be considered indi- 
vidually in prescribing a diet, as for example it would be 
actually wrong to order a diet with high fats for a person 
already overweight, or a diet principally vegetable and fruit 
for a person suffering from inanition. 

Chronic Constipation. — The following diet will be found 
generally useful, having due regard for the foregoing factors. 
On rising drink a glass of water, one third to one-half 
grape juice or two glasses of plain water. 

Breakfast: Stewed fruit or fresh fruit. Oatmeal or petti- 
john breakfast food (25 per cent, bran), with cream 
and sugar, white or brown ; or cornmeal mush with 
molasses, golden drip or maple sugar; eggs or bacon, 
whole- wheat bread or bran bread or Grant's health 
crackers (bran) with fresh butter, if it is obtainable 
(one eats more butter when it is fresh than when 
salted), or cooked bran may be mixed with the 
morning dish of cereal. 
Midmorning: Drink a glass of water or eat some dried 
fruit, figs, dates or Bordeaux prunes, or fresh fruit 
in season. 
Luncheon or Supper: Small piece of meat or fish, two 
green vegetables from the list, whole-wheat bread 
and fresh butter, bran bread or crackers. Fruit 
fresh or stewed. Prune or fig pudding, or salad 
with oil dressing. 
Dinner: Grapefruit, vegetable soup. Entree of fish or 
egg with caper sauce or plain. Small piece of fowl 



400 DIET IN DISEASES OF THE INTESTINES 

or red meat with fat. Two or more green vege- 
tables from list, taken in double quantity, and 
cooked with butter or oil, unless it is necessary to 
keep the weight down. Salad of celery and fruit 
or lettuce and other vegetable with ship biscuit 
or bran cracker. Cold slaw. Olives, radishes. 
Dessert — a fruit pudding, fresh fruit, stewed fruit, 
figs, nuts, raisins. 
Bedtime. Two figs, prunes or several dates. 
Of course one is not supposed to eat all the articles men- 
tioned at one meal, but a choice made for each, varying it as 
to fats or vegetables, as necessity requires. 

Drinks. — Coffee, buttermilk, cider, water, Vichy, grape 
juice, raspberry vinegar or some sweet wine, if one must 
have alcohol. 

The use of agar-agar preparations is sometimes recom- 
mended in these cases to give bulk to the feces owing to their 
power of taking up water. But much the same result can be 
obtained by the use of good amounts of vegetables and fruit. 
Spastic Constipation. — In this form of constipation it is 
necessary to furnish considerable bulk to the feces, but keep- 
ing all the foods soft and non-irritating, also include a large 
percentage of fats and oils, making an especial point of 
this latter feature. It is here that the mineral oils may have 
their best effect and should be tried freely and thoroughly 
and as well, the injecting of 2 to 4 ounces of some bland oil 
into the rectum at bedtime. For this purpose one may use 
olive, cottonseed, peanut or sweet oil. Larger quantities 
are often recommended, but serve no more useful purpose 
than the small amount. In this diet the fruits should be 
freely used, but not those with seeds or skins; and raw, 
rough or uncooked vegetables must be left out of the diet. 
Potatoes, spaghetti and all cereal foods are good, except 
oatmeal or bran preparations and, of course, fish, eggs and a 
moderate amount of meat, free of connective tissue, are all 
allowable. 

If one will keep in mind the facts already stated, that the 
diet must contain a greatly increased bulk of soft vegetables 
and fruit and as large an amount of oils and fats as one can 
digest readily, the diet may be easily constructed. It is 
often better to take all the vegetables as a puree or after 
being passed through a colander. 

Obstructive Constipation. — The texture of the diet in this 
condition will depend largely upon the degree of obstruction ; 
if slight, it will be only necessary to exclude all coarse food 
from the diet which will leave us much the same diet as has 



CHRONIC CONSTIPATION 401 

been recommended for spastic constipation. When the 
obstruction is more marked or severe, it will be necessary to 
confine the foods to those which leave the stomach largely 
in fluid or semifluid form, such as malted milk, citrated milk 
(i grain of sodium citrate to the ounce of milk), cream and 
puree soups, cream, meat cut very fine or scraped. Soft 
eggs. Mashed potato, oils, butter, fine cereal gruels, ice- 
cream and syrups. Of course when an obstruction reaches 
this point it becomes a surgical condition and should be so 
treated. The only cases of severe obstruction in which it is 
necessary to consider the diet for any but a few days, are 
those cases, which, for one reason or another are inoperable. 

The Use of Mineral Oil in Chronic Constipation. — This 
oil comes in various grades, heavy and light, made here and 
abroad, formerly in Russia, hence the common name "Rus- 
sian mineral oil." Many cases of chronic constipation are 
greatly helped by varying doses, from a tablespoonful morn- 
ing and night to double that dosage or more. Still others 
find that a tablespoonful at bedtime is amply sufficient, in 
short, each patient has to find the individual dose suited to 
the needs of their case. Many patients cannot take this oil 
at all, for although it is not absorbed, the entire amount in- 
gested being recoverable in the feces, it not infrequently 
interferes with the normal digestive processes giving rise 
especially to intestinal indigestion, characterized by the 
symptoms of a mild enteritis accompanied by loss of appe- 
tite. Whether this acts partly on account of the depressing 
effect of oils on gastric secretion or possibly on account of 
the same effect on the intestinal enzymes or again by me- 
chanically preventing the digestive juices from attacking the 
foods is not definitely known. The essential thing, however, 
to remember is that it does not agree with all patients by any 
means and its effect on digestion must be watched. After 
considerable investigation in regard to the different mineral 
oils and the different methods of giving it, Bastedo 1 came to 
the following conclusions, which are borne out by clinical 
experience. 

Dosage. — Half an ounce to three ounces a day. In the 
same patient, the same amount of each of the oils was re- 
quired, i. e., heavy and light oil. 

Frequency of Dose. — The same amount daily seemed as 
efficient when given in one dose as when given in divided 
doses two or three times a day. 

Number of Stools. — To produce one or two copious stools a 
day the dose required varied considerably, but there was no 

1 Jour. Am. Med. Assn., 1914, lxiv, 808. 
26 



402 DIET IN DISEASES OF THE INTESTINES 

difference noted on account of difference in the specific grav- 
ity or character of the oils. 

So far as therapeutic results are concerned the differences 
in the action of the three varieties of liquid petroleum, 
namely, light Russian liquid petrolatum, heavy Russian 
liquid petrolatum and American liquid petrolatum, are too 
slight to be of importance. 

Character of Stools.— The stools were soft, usually formed, 
sometimes mushy, obviously greasy. They had a peculiar 
odor described as sour. Their consistency varied with the 
dose, but was the same for the different kinds of oil. 

Admixture of Oil with Other Ingredients of Stools. — Generally 
well mixed, but from time to time a patient would have a 
stool of free oil. This occurred with all varieties of oil. (It 
necessitated reduction of the dose, and if then the bowels 
were not active enough, the administration in addition of 
cascara, aloin, etc.) 

The increase in the quantity of oil used in America has 
stimulated production on this side of the water until now all 
grades of mineral oil may be had of native manufacture 
which are in every way as good as the imported brands. 

INTESTINAL ATONY. 

This condition affects chiefly the muscular coat of the 
large bowel and results in constipation, in fact a large 
majority of cases of chronic constipation are the result of 
an atonic colon. 

The diet to combat intestinal atony should be much the 
same as that recommended for chronic constipation and con- 
tains as large a percentage of cellulose and fats as possible. 
Suitable foods are: the breads which should be those made 
with whole-wheat flour, rye flour or bran; vegetables; the 
best varieties of which are those having the largest residue, 
such as the cabbage family, spinach, string beans or dried 
beans, peas, parsnips, sweet potatoes, beet tops, etc.; the 
rough cereals as oatmeal (Irish) or Pettijohn (which is 25 
per cent, bran) or Kellogg's cooked bran, which can be eaten 
alone or mixed with other cereals. All fruits, fresh stewed or 
dried are useful and should be taken in some form at least 
three times a day. Molasses, honey, marmalade and maple 
syrup are all stimulating to the intestine. The best fats 
are cream, olive oil, butter and fat meats — as bacon. Pro- 
tein foods may be unrestricted in kind but should be some- 
what limited quantitatively, for when taken in large amounts 
they tend to spoil the appetite for the more bulky and neces- 
sary vegetables and fruits. 



APPENDICITIS 403 

As additional measures, massage of the colon and elec- 
tricity (given with one electrode in the rectum) assist in 
waking up a sluggish bowel, and general hygiene. 

APPENDICITIS. 

Acute Appendicitis. — Acute appendicitis whether catar- 
rhal, suppurative, gangrenous or perforative, is essentially a 
surgical disease and should be so considered from the onset. 
There are certain conditions, however, under which acute 
appendicitis may arise, which, for one reason or another 
make an operation either impossible or inadvisable, as for 
example, if the patient absolutely refuses surgical aid, in 
spite of knowing the dangers of that course; when surgical 
aid is not to be had or only a very poor variety; in people 
of great age where it is feared the shock of any operative 
interference would be fatal and last but not least important, 
in those cases which have been neglected until general peri- 
tonitis is present with distention and an almost moribund 
condition, when operation is considered as a last hope. These 
last-named cases almost invariably die if operated upon and 
are likely to die if they are not, but a few may survive care- 
ful medical treatment. Of course, it is a matter of very 
fine distinction and surgical judgment when this point is 
reached and rejection of surgery should not be encouraged 
except after mature deliberation and full consultation. 

In all these conditions it will be necessary at times to turn 
to general medical care without operation and the dietary 
and general routine care of such patients are of the utmost 
importance. Formerly in these conditions reliance was 
placed on opium in full doses, and many cases were success- 
fully carried through with its aid. The effectiveness of 
opium depended on the fact that it quieted the bowel, tend- 
ing to stop peristalsis and the consequent transference from 
the iliac fossa of the septic material all over the abdominal 
cavity, an easy matter when peristalsis is active; and no 
doubt also to the fact that it helped to destroy the appetite, 
and so limit distention from fermentation of ingested food. 
Of late years this method has fallen into disrepute because 
of the fact that opium so completely masks the symptoms in 
the early stages that one cannot tell of the progress of the 
disease and one is apt to miss the true significance of the 
patient's condition. 

Ochsner's Treatment for Appendicitis. 1 — In the early 
nineties, Ochsner devised the treatment which goes by his 

1 Handbook of Appendicitis, 1906, p. 132. 



404 DIET IN DISEASES OF THE INTESTINES 

name and although it has been the storm center of many 
arguments, under the conditions mentioned, where operation 
is impossible or inadvisable, it remains today the best method 
we have and often gives surprisingly good results. In a word 
it consists of withholding everything by mouth, forbids ca- 
tharsis and insists upon gastric lavage when there is nausea 
or vomiting and depends upon rectal absorption of small 
amounts of predigested food and salines. 

Ochsner bases his recommendation of this method founded 
on experience on these two cardinal facts. 

1. "The anatomical location of the appendix m. kes it 
easy to be shut off from the general abdominal cavity, if the 
surrounding structures remain at rest for a time." 

2. "If at rest, the cecum, omentum and small intestine 
surround the diseased appendix, no matter what its patho- 
logical condition — so shutting it off from the general cavity. 

The effect of taking food is to excite peristalsis and no 
matter how light the food, it may, by exciting peristalsis, 
carry septic material all over the peritoneum and the gas 
produced by food passing down disturbs an inflamed appen- 
dix. He therefore forbids absolutely everything by mouth. 
This does not mean that a little broth or water or milk may 
be given, but means that at first nothing is to pass the lips. 
Ochsner further states "no matter whether the patient has 
a catarrhal appendicitis with or without a foreign body in 
the appendix or whether the appendix is gangrenous or per- 
forated he will almost invariably recover, if from the begin- 
ning of the disease absolutely no food is given by mouth." 

He also insists on gastric lavage if there is nausea or vom- 
iting or if the patient begins his appendiceal symptoms 
shortly after a meal. This removes material that excites 
peristalsis and will later surely ferment and form gas if it be 
not promptly removed. The lavage is to be repeated at 
least once if the nausea and vomiting recur; usually after 
the first twenty-four hours water may be given by mouth 
in small amounts, but if peristalsis is thereby excited it must 
be given only by rectum. 

The last feature of Ochsner's treatment is to give nutrient 
enemata every three to six hours not to exceed 4 ounces at 
a time, made up of }4 or 1 ounce of some predigested commer- 
cial food in 3 or 4 ounces of normal saline solution and 
given by a small tube after adding twenty drops of tincture 
opii deodorata, for an adult, to the first feeding, and one- 
half that amount to the other feedings (children in propor- 
tion), unless the patient is entirely free of pain or restlessness. 
These directions are to be followed until the patient is well 



APPENDICITIS 405 

along toward recovery and in very severe cases he continues 
the rectal feeding for ten days or even longer. Theoretically 
there is objection to giving anything by rectum, as peristal- 
sis is at once excited in the entire length of the large intestine, 
as it is so clearly shown by the fluoroscope when bismuth or 
barium are mixed with the enema. Practically, however, 
this objection does not seem to invalidate the treatment, 
probably because the peristalsis is along definite and fairly 
fixed lines, unlike the movement of the small intestine. 

Of course, as shown in the chapter on Rectal Feeding, 
these enemata furnish little besides fluid, although some 
protein in the form of amino-acids and some of the sugars 
are absorbed in solution. Probably completely pancrea- 
tized (" peptonized") milk (two hours) after being sterilized 
is quite as efficient as the commercial predigested foods. 

Ochsner himself is a strong advocate of surgical interven- 
tion in appendicitis and only recommends the foregoing 
when an operation is either impossible or inadvisable, as 
already explained. 

Chronic or Larval Appendicitis. — In chronic appendicitis 
or larval appendicitis, conditions are quite different from the 
acute variety and while operation is advisable when a diag- 
nosis is made, it may for one or another reason, be necessary 
to postpone it until some later time. Then too, when not 
acutely ill it is not always so easy to persuade one's patients 
to undergo the operation, although they should be warned 
that an acute exacerbation is possible at any moment which 
may make an operation imperative. If, on the other hand, 
it is necessary to tide these patients along for one or another 
reason, dietary regulations will help in reducing the symp- 
toms in many cases, until an operation can be done. 

In very many of these patients there is an accompanying 
constipation which is more or less marked and in them the 
diet as advised for chronic constipation will be of distinct 
value, for by facilitating the constant removal of fecal 
masses from the colon the congestion of the caput coli and 
appendix region will be considerably reduced, so lessening 
at all events the pain and many of the symptoms of chronic 
indigestion which these patients have, also any pressure on 
the appendix from impinging fecal masses will be relieved. 
In these patients it is advisable to give a morning dose of 
some one of the saline cathartics, at least until the bowels 
act regularly themselves. The following mixture as recom- 
mended to the author by R. Freeman, has proven its value 
many times. Sodium salicylate 5i (4 gm.), sodium phos- 
phate 5ss (16 gm.), sodium sulphate 5iss (45 gm.), giving a 



406 DIET IN DISEASES OF THE INTESTINES 

teaspoonful of this combination (more or less as required), 
in the early morning, at least one-half or three-quarters of 
an hour before breakfast. It should be dissolved in a little 
hot water and the glass filled at least three-quarters full with 
cool, but not cold water. The addition of the salicylate 
salt helps to reduce fermentation and consequent distention. 
The chronic cases with constipation have the latter feature 
lessened by the use of some preparation of mineral oil, 
provided it does not disagree (see Chronic Constipation). 

When constipation is not a feature of the condition a diet 
containing the minimum amount of fermentable vegetables 
is advisable, i. e., leaving out potatoes, onions, cauliflower, 
cabbage, Brussels sprouts, sweets, fresh breads or uncooked 
starches, pies, cakes, syrups, fried foods or foods that are 
famously indigestible (see Section on Indigestion). Here, too 
it is advisable to give a smaller dose of the saline or the 
above-mentioned salts which help to drain the appendix 
and reduce congestion about it. Rest before and after meals 
is advisable and it is especially desirable that these patients 
should eat without haste and thoroughly masticate their 
food. 

The author has seen many cases in which this plan of 
treatment has reduced the symptoms to a minimum and in a 
number relieved the patients entirely, although, of course, 
it is presumable that further trouble will recur at a later 
time, particularly if the appendicitis is of the chronic invo- 
luting variety. 

CHRONIC TYPHLITIS AND PERITYPHLITIS. 

The dietary routine for these conditions is much the same 
as that given for chronic appendicitis, although here oil and 
fat foods play a more prominent part and the injection of 
two or three ounces of oil in the rectum at bedtime is most 
useful. In some cases it will be necessary to revert to the 
diets recommended for chronic colitis of which these condi- 
tions are often a part. The use of salines is also useful in 
keeping the caput as free of feces as possible, and a moderate 
dose of a mild saline cathartic in the early morning is helpful. 

INTESTINAL AUTO-INTOXICATION. 

The entire subject of auto-intoxication is far from clear, 
particularly in its clinical bearings, and there may be found 
great difference of opinion among biological chemists as^ to 
the significance of the products of intestinal fermentation 
and putrefaction in their relation to conditions of actual 



INTESTINAL A UTO-INTOXICA TION 407 

disease or pathological states. Thus Taylor 1 says that 
intoxication by resorption of the digestive juices by products 
of normal digestion and by abnormal products of digestion 
is not proven experimentally and probably does not exist 
and in "normal bacterial disintegration of food-stuffs in the 
alimentary tract no known toxic substance is found," for 
the products of carbohydrate fermentation, formic, acetic, 
butyric, valerianic, proprionic, lactic, succinic acids and a trace 
of oxalic acid are not toxic. So too, according to Taylor, 
although protein putrefaction yields phenol, skatol, indol 
and cresol from animo-acids and hexone bases, none of these 
are toxic. Also there is "no constant relation between the 
protein ration and the output of aromatic substances, and a 
high urinary output of aromatic substances indicates active 
putrefaction in the colon, which may be innocuous or not. 
On the other hand, a low output need not indicate a low 
degree of bacterial activity in the intestines and need not 
speak against a bacterial intestinal intoxication. 

Cytolytic degeneration seems allied to the process of fer- 
mentation, the functions of the tissues are disturbed by the 
cytolyses and an auto-intoxication may result, also the prod- 
ucts of tissue degeneration may be toxic themselves, so that 
according to Taylor again it is not possible to separate auto- 
intoxication from the general pathology of metabolism. 

In so-called gastro-intestinal auto-intoxication there is no 
constant relation, according to the same authority, between 
constipation, excess of indican and conjugate sulphates in 
the urine, nor does the degree of these substances bear any 
relation to the severity of the symptoms. 

Combe, 2 on the other hand, is an enthusiastic supporter of 
the gastro-intestinal origin of certain toxic states of theorgan- 
ism and marshalls his proofs in very clear and logical order. 
We all know that bacteria play a large part in the digestive 
processes and the questions are asked: 

1. Is the microbic intervention useful to the body? 

2. Is it indispensable? 

3. Can it become harmful? 

1. The answer to the first is positively affirmative, as the 
bacteria digest foods as do the enzymes and in some instances 
digest portions of the food (cellulose) which the enzymes 
cannot. 

2. The bacteria are also indispensable as proven by Nut- 
tall, Thierfelder 3 and Schottelins 4 who showed that animals 

Osier's Mod. Med., vol. ii, 503. 
2 Auto-intoxication. 

3 Ztschr, f. phys. Chem., vol. xxii, 71. 
4 Arch, fur Hyg., vol. xxiv, 210, 



408 DIET IN DISEASES OF THE INTESTINES 

born and raised aseptically did not thrive or, in many in- 
stances, live at all. 

3. In answer to the third question as to the possible harm- 
ful qualities of bacteria in digestion, Combe gives positive 
assent, although it has been strongly combated by the Ger- 
man school, who admit the symptomatology and the prob- 
able focus but find the proofs insufficient. He further forti- 
fies his position by pointing to the autotoxic and detoxifying 
powers of Nature's three lines of defense against intoxica- 
tion found in the intestinal epithelium, liver, glands of in- 
ternal secretion and external secretion as e. g., the kidneys, 
through which intestinal toxins are constantly eliminated. 

Phenol, indol and skatol are all formed in the intestine as a 
result of putrefaction of nitrogenous food-stuffs, principally 
meat. Phenol is formed in the large intestine as a result of 
bacterial activity in the presence of stasis there, but when 
small in amount is oxidized in the organism or is eliminated 
by the bowel and only when the formation exceeds the oxidiz- 
ing powers is it excreted by the urine. Indol is formed in 
the small intestine as a result of stasis in this part of the 
bowel and never when the stasis is in the large intestine. It 
is oxidized into indoxyl, which combines with sulphuric acid 
in the liver to form indozyl sulphuric acid; this appears in 
the urine as a salt of potassium, potassium indoxyl sulphate 
or indican. This substance in turn is oxidized into sulphuric 
acid and indoxyl, the latter into indigo red or indigo blue 
if an oxidizer is present. 

Both indol and phenol excretions depend on : 

1. The composition of the food (which varies). 

2. On the degree of peristalsis. 

3. On the power of absorption. 

4. On putrefaction intensity. 1 

It is strongly disputed whether indicanuria has any effect 
in producing symptoms of so-called auto-intoxication but 
there seems little doubt but that it is at least the index for 
other conditions which result in symptoms, and the associa- 
tion of marked indicanuria and evidence of renal irritation 
(as a trace of albumin, casts, etc.), is too definite to be dis- 
missed without adequate explanation, particularly as re- 
lieving the indicanuria often results in a return to a normal 
urinary output. The effect of the indican perhaps while 
not deleterious in itself may be to cause renal irritation and 
consequent reduction in the kidney's power for excretion of 
other toxic substances at present unknown but standing in 

1 Combe; Auto-intoxicatiom, p. 61. 



INTESTINAL A UTO-INTOXICA TION 409 

a causal relation to the symptoms of intoxication. At the 
same time there is no end of clinical evidence that when 
symptoms of a toxemia are present in connection with con- 
siderable amounts of indol in the urine, relief is seldom or 
never obtained until measures are adopted to restrict its 
formation (diet) and to favor its elimination (catharsis and 
intestinal irrigation). 

On the other hand, there are undoubtedly many cases of 
indicanuria which are entirely without symptoms, so that 
while the specific variety of auto-intoxication depends on 
chemical, physiological and pathological facts too intricate 
to be as yet made out with clearness and it is not possible 
to speak of treatment based on specific etiological factors, 
we know something of the course of development of the in- 
testinal poisons from fermentation and putrefaction 1 and 
the clinical conditions that lead directly to it, as well as the 
factors that modify it. 

Dyspepsia and stasis either gastric or intestinal; diseased 
conditions of the intestinal walls with consequent lessening 
of the defense mechanism; parasites; diminished activity of 
the antitoxic organs; bad eating habits, hurry, working too 
soon after a meal, all may be of etiological importance. 

Dietetic Indications for Intestinal Auto-intoxication. — 
When one comes to consider the necessary factors in dimin- 
ishing nitrogenous intestinal putrefaction one finds that 
Combe 2 sums up the indications as follows: 

1. Modify the intestinal culture medium in which the pro- 
teolytic bacteria thrive by. 

(a) Introducing an antiputrefactive lactofarinaceous diet. 

(b) Introducing antagonistic bacteria into the intestinal 
medium. 

2. Diminish the vitality of the proteolytic bacteria in the 
intestine by means of germicidal medicines (there is as yet 
no known way to accomplish this satisfactorily). 

3. Evacuate the proteolytic bacteria and their products 
by intestinal lavage. 

The first indication, namely, that of modifying the culture 
medium is the one with which we are particularly concerned 
and leads us to a study of diet for this condition. 

General Indications for Diet: 
Nitrogenous Foods. 

1. Diminish these as much as possible, keeping to the low 
level of physiological requirement, 40 to 60 gm. (ij^ to 2 
oz.) of protein, per diem. 

1 Forchheimer: vol. ii, 664. 2 Auto-intoxication, p. 234. 



410 DIET IN DISEASES OF THE INTESTINES 

2. Absolutely prohibit those forms of nitrogenous foods 
that favor the development of putrefactive bacteria, par- 
ticularly animal protein except milk, e. g., meat, fish and eggs. 

3. To choose among these milk in one of its many forms, 
whole, skimmed, zoolak, koumyss, buttermilk, kefir, loppered 
milk, cream or pot cheese. 

Fatty Foods. 

1. Avoid meat fat as increasing putrefaction. 

2. Give fat best in the form of fresh butter and cream. 
Farinaceous Foods. 

1. Give as large a proportion of farinaceous foods as pos- 
sible, saturate the intestines with them, giving five or six 
meals in the proportion of five times as much farinaceous as 
protein foods, whenever the latter are given. 

2. In auto-intoxication from acute enteritis an exclusive 
farinaceous diet must be given for several days. 

3. In auto-intoxication due to chronic enteritis, the diet 
should be lactofarinaceous giving later a little meat or eggs. 

4. In ordinary auto-intoxication milk mixed with fari- 
naceous food is best, for the lactose of the milk on account of 
its lactic acid-forming abilities is a strong antiputrefactive 
element. 1 

Foods to Especially Avoid. — Bouillon, meat soups, meat 
juices and jellies, meat extracts, white of egg or dishes which 
are made of it. Milk, unless mixed with farinaceous food. 
High or tainted meats or those which decompose rapidly, 
game, rare or raw meats, fish, shell fish. 

In severe auto-intoxication absolutely no meat should be 
taken and when it is begun later, only in small progressive 
quantities, not forgetting that it should be taken with five 
times its bulk of farinaceous foods. 
Foods to take. 

Fruits raw or cooked. 

Vegetables, thoroughly cooked and soft, all farinaceous 
foods, as rice, noodles, macaroni, puddings, puree of vege- 
tables, bread, yolk of eggs. Sauerkraut is a valuable anti- 
putrefactive food. 
Modified Sample Menus. Farinaceous without Meat. 

7.30 a.m. Cereal prepared with water or milk. Rolls 

and fresh butter. 
10.00 a.m. Some form of gruel made with milk or water. 
12.30 p.m. One or two yolks of eggs, raw or boiled, maca- 
roni, rice, farina with salt and fresh butter. 
Farinaceous pudding. Rolls and butter. 
Later fruit and soft green vegetables. 

1 Combe: Auto-Intoxication. 



INTESTINAL A UTO-INTOXICA TION 411 

3.30 p.m. The same as at 10.00 a.m. 
7.00 p.m. Same variety as at 12.30 p.m. 
10.00 p.m. Infusion of chamomile, peppermint, fennel, 

or anise. 
After eight to ten days of this, add potatoes, puree or baked. 
Whortleberry juice or jelly. No fluids with meals. 

Later tea, coffee, cocoa, vegetables, and fruits, may be 
added in the order named with a little meat, first at one and 
then at two meals, watching the effect. 

In choosing a diet one must also be somewhat guided by 
the conditions so often associated with intestinal auto- 
intoxication, e. g.j stasis, chronic constipation, torpid liver 
or actual hepatic disease and circulatory disorders. Jack 1 
recommends loppered milk diet in auto-intoxication associ- 
ted with emaciation or not, given with well-cooked fruit 
and cereal, thus one pint of loppered milk with buttered- 
toast or a cheese or butter sandwich with baked apple or 
stewed fruit every two hours. After ten or eleven days increase 
the diet. When on regular diet again he advises taking as 
much as five pints of the loppered milk — one pint at each meal 
and one between meals. (This is probably too much for 
the average case.) 

A sample diet covering the most usual associated condition, 
viz., that of chronic constipation or intestinal stasis might 
be chosen somewhat as follows: 

Early morning, one-third or one-half glass of grape juice 
with equal amount of water. 

Breakfast: Glass of milk or buttermilk with cereal and 
cream (tea or coffee later). Bread and fresh butter. 
Fruit. 
Midmorning: One-half glass of buttermilk and slice of 

bread. 
Dinner or Supper: Cream vegetable soup made without 
stock or thickened with flour. Yolk of two or 
three eggs poached or scrambled; macaroni, cream 
cheese, potato, rice, baked farina, green vegetables 
(that grow above ground). Glass of milk or butter- 
milk. Bread and fresh butter. Farinaceous pud- 
ding with fruit sauce or stewed figs, prunes, apricots, 
pears, cherries or peaches. 
Midafternoon: Cream cheese and crackers. 
At Bedtime: One-half to one glass of buttermilk with 
two or three toasted crackers and several dates or 
figs. 

1 Buffalo Med. Jour., 1917-18, xcix, 501. 



412 DIET IN DISEASES OF THE INTESTINES 

This should be kept up for a long enough time to get rid of 
the subjective symptoms and any abnormal urinary find- 
ings, and then little by little one may add a little meat and 
other foods, gradually returning to a normal dietary but for 
a long time keeping the protein at a low level as already 
indicated before. 

The treatment should be begun with a mercurial purge 
and the use of some laxative or mineral oil continued for 
some time. When the symptoms are severe great assistance 
is obtained from high colon irrigations with normal saline 
or a I per cent, solution of ichthyol. 

General bodily exercise regularly every day and hygiene 
are all of great assistance in ridding the gastro-intestinal 
tract of the toxic materials. 

In some instances a complete change of life, a trip to 
Europe or elsewhere, taking the patient out of his usual 
routine may be necessary to accomplish the end desired. 
The usefulness of this has been proven more than once in 
the writer's experience. 

HEMORRHOIDS. 

Hemorrhoids are caused by a dilatation of one or more of 
the veins at the anal ring which at any time may be throm- 
bosed. The dilatation is due either to a temporary and 
local obstruction to the return venous flow, as in constipa- 
tion, or fecal impaction, or just mere straining at stool, or 
to a permanent interference with the return flow, as seen in 
cirrhosis of .the liver or chronic cardiac disease. 

The dietary prevention of the temporary venous obstruc- 
tion is very important and one can do much to obviate the 
production of hemorrhoids by giving a diet which will jbe 
laxative such as is recommended in chronic constipation, 
including as it does a large amount of cellulose in green vege- 
tables and fruits, fresh and dried; oils, fats and liquids in 
excess. 

When the hemorrhoids develop as a result of straining and 
tenesmus in prolonged diarrhea, a diet to control the loose- 
ness will be of use as in chronic diarrhea, unless one can find 
the direct cause of the diarrhea and correct it. 

In the cases of hemorrhoids dependent on hepatic or car- 
diac disorders it will be necessary to insure regular bowel 
movements, using an anticonstipation diet so far as one can 
in consideration of the underlying causes. Measures directed 
toward the relief of the hepatic or general intestinal conges- 
tion are necessary in addition to the suitable diet. 



HIRSCHSPRUNG'S DISEASES 413 

HIRSCHSPRUNG'S DISEASE. 

In this disease, which is a chronic or congenital dilatation 
of the colon, there are certain dietary indications which are 
designed to combat rather the symptoms (which are often 
secondary to the condition, such as chronic constipation and 
stasis with at times symptoms of toxemia) than the dilata- 
tion itself. There is one exception to this, namely, that 
foods which are particularly prone to be stored up in the 
colon and increase the dilatation should be avoided, as for 
example an excess of tough cellulose. 

The diet recommended for chronic constipation is best 
suited to this disease with the precaution that all vegetables 
and fruits should be soft when fed and not given in indiges- 
tible bulk, although the total quantity of such foods should 
be great. 

It would seem as if in this disease the regular use of min- 
eral oil might accomplish much by its lubricating qualities, 
and certainly deserves a trial, which, with massage of the 
colon, may help to preserve the muscular tone of the intes- 
tine. 

A surgical procedure is the only permanent way of reliev- 
ing Hirschsprung's disease, either as a colectomy or iliosig- 
moidostomy. 



CHAPTER XXIII. 

DISEASES OF THE ACCESSORY DIGESTIVE GLANDS 

The action of these glands and their secretions are so 
indissolubly connected with the processes of digestion that 
the consideration of one implies consideration of both. We 
have dealt with dietetics of diseases of the digestive tube 
separately, but as a matter of fact, unconsciously we are 
compelled to take account of the state of the accessory glands 
in doing so, and of making allowances for their integrity or 
lack of it. On the other hand, there are certain diseases or 
pathological states of these glands that arise, which demand 
attention aside from the questions of digestion, as well as 
the bearing of these conditions on the normal utilization of 
food-stufTs, and with some of these we are now particularly 
concerned. 

DISEASES OF LIVER AND GALL-BLADDER. 

It is much to be regretted that the dietetics of hepatic dis- 
eases cannot be more serviceable as curative agents and still 
more to be regretted that most people are not willing to exer- 
cise the common sense and self-restraint in drinking and eat- 
ing, the failure of which in so large a measure is responsible 
for the frequency of diseased conditions in these organs. 

In other words, dietetics here are much like locking the 
stable door after the horse has been stolen, for the dietetic 
prophylaxis is all important. After the damage is done 
patients are willing to go anywhere and spend any amount 
to be rid of their troubles or do anything that offers a chance 
in the prevention of a return or continuance of their symp- 
toms. 

In the matter of diets for hepatic disorders and disease we 
could act a good deal more intelligently if we had a simple 
and reliable method for testing hepatic functions, for if our 
choice of a diet could be made to depend on definite know- 
ledge of just what food elements were poorly metabolized 
by the liver, we could choose a diet especially adapted to the 
individual case. 

The methods in vogue for testing liver functions are too 
uncertain or too complicated to be of much practical use, 
although there is no doubt but that there is progress being 
made in this direction. 

414 



DISEASES OF LIVER AND GALL-BLADDER 415 

Strauss used ioo to 150 gm. levulose to test liver functions, 
a resulting levulosurea indicating a disturbed hepatic func- 
tion. As a matter of fact, most diseased livers respond to 
this test, but in many of the cases of cirrhosis the glycogenic 
function is perfectly well preserved and we get no resulting 
levulose in the urine. 

Opie 1 found that when the liver was poisoned by certain 
substances as, e. g., chloroform, the susceptibility to intoxica- 
tion is greatest after a diet of fats, less after meats and least 
in animals fed on carbohydrates. This by analogy can be 
used in choosing the diet in threatened cholemic states where 
the liver cells are failing in their power to functionate, over- 
whelmed as they are by the poisons in the system, here 
carbohydrates should be given fully and may even be given 
subcutaneously, as a 5 per cent, solution of glucose. 

Dietetic Prophylaxis. — This question is practically a state- 
ment of the etiology of many abnormal liver conditions and 
while it is to be feared that few will heed advice until exper- 
ence has taught its bitter lesson, it is certainly a necessary 
thing to state how most of these diseases may be avoided, 
excepting of course those due to direct infectious agencies. 

It is only necessary to remind the reader of the physiology 
of the liver to see that almost everything absorbable that is 
ingested finds its way sooner or later to the liver, which is 
endowed with extraordinary powers. These powers may be 
spoken of as the detoxifying, lipogenic, glycogenic and urea- 
forming functions. In a normal liver these operate to per- 
fection, but in disease are more or less disturbed or per- 
manently disabled. For the exact mechanism by which 
this is accomplished, one is referred to Physiology, and all 
that is necessary here is to enumerate the "don'ts" of diet- 
etics to point the way to a preservation of normal functioning. 

The excessive ingestion of any one of the food elements, 
protein, carbohydrates and fat will lead eventually to dis- 
turbed liver function, and a continuance of this results in 
permanent damage to the cells. Among the articles of food 
especially to be avoided are condiments of all sorts, alcohol, 
vegetables rich in irritating oils, such as garlic, radish and 
horse-radish and the continued use of phosphorus or arsenic 
in course of treatment. This does not mean that one must 
go through life without the use of any condiments, for a 
little at times can be successfully detoxified by the liver, but 
taken in large amounts or continuously they form a very 
distinct danger to the integrity of the cells by chronic irri- 

ijour. Exp. Med., 1914, xxi, 1. 



416 DISEASES OF A CCESSORY DIGESTIVE GLANDS 

tation and the production of connective tissue. Alcohol is, 
of course, the chief offender and it hardly seems necessary 
to mention this point, it is so generally known and recognized 
even by the laity. Spirits as whiskey, gin, brandy, etc., are 
especially bad and all other alcoholic drinks directly in pro- 
portion to their alcohol content. When taken on a full 
stomach and largely diluted they are of course, least irritat- 
ing, but the dilution does not lessen the absorbability of the 
alcohol but merely spreads it over a longer time, giving the 
liver a better chance to handle it. Especially bad are un- 
diluted spirits on an empty stomach, as cocktails or neat 
spirits taken as an appetizer before meals, as here the ab- 
sorption is quickest and most complete and is apt to be re- 
gularly repeated. While the spirits have a tendency to pro- 
duce cirrhosis, the beers do so also, but to less extent, and 
their damaging effects are seen as well in the deposition of 
excessive amounts of fat in and about the liver cells and as 
a fatty degeneration of the cell itself. With the new pro- 
hibition laws it is probable that cirrhosis of the liver will 
become comparatively a rare condition. 

Acute Hepatic Congestion. — This is caused frequently by 
overeating and drinking and from a dietetic point of view 
requires starvation or semistarvation until the appetite, 
which is usually completely lost, returns. During this day 
or two of starvation water can be given freely, and as soon 
as the patient is able to take food he may be given small 
amounts of milk, skimmed or whole, diluted with alkaline 
waters; also gruels, cream soups, milk toast and soft cereals, 
custards, soft green vegetables, chicken and so back to full 
diet, giving the articles in about the order listed. 

This condition of acute congestion of the liver is usually 
designated by the layman as a "bilious" attack, at all events 
that covers the situation, although nobody knows just what 
a " bilious" attack is, it seems to be so many things to dif- 
ferent people. 

Acute Catarrhal Jaundice or Gastroduodenitis with Jaun- 
dice. — In this condition we have not only the catarrhal inflam- 
mation of the bile ducts but primarily of the stomach and duo- 
denum, so that the catarrh of this part of the digestive tract 
must be taken into account in the choice of a diet. Fortu- 
nately the same diet fits both conditions. As fat is very 
badly digested in this, it is best to reduce it to a minimum 
until the jaundice is largely over; to this end skimmed milk 
is an ideal diet, although here again a day or two of starvation 
at the outset may be quite the most serviceable procedure, 
provided water is given in large amounts. After the skimmed 



DISEASES OF LIVER AND GALL-BLADDER 417 

milk we can give broth, gruels and soft foods generally in pro- 
gressive order. An early morning saline laxative is essential, 
particularly when constipation is marked, but all cases are 
benefited by it, as it has a favorable influence on the gastric 
and duodenal catarrh. According to Forchheimer jaundice 
causes a hyperchlorhydria in direct proportion to its intensity, 
and the diet must be chosen with this in view, avoiding 
stimulating acid or irritating foods. 

Chronic Hepatic Congestion. — This is usually passive and 
due to cardiac disease with failure of compensation. The 
diet should be light, non-stimulating and attention directed 
to the cause of the congestion. 

Portal Cirrhosis. — Although this disease does occur occa- 
sionally in children and young adults without known cause, 
it is for the most part, par excellence, the disease of retribu- 
tion and can usually be traced to chronic hepatic irritation 
from overindulgence in irritating foods and drinks, especially 
alcohol. Where the diagnosis is fairly certain and especially 
in the earlier stages, it is necessary to institute at once a 
rigid milk cure (as milk is nourishing and absolutely non- 
irritating), given continuously and alone for from four to 
six weeks, 1 2 or 3 quarts per diem, diluted with soda water, 
Vichy or Apollinaris or flavored with tea, coffee or cocoa. 
This diet reduces intestinal putrefaction to a minimum, so 
causing less hepatic irritation, the fat is in emulsion and ab- 
sorption can take place in spite of an intestinal catarrh. 2 
When nausea or vomiting are sources of trouble, skimmed 
milk often agrees better than whole milk. 3 

After this period of milk diet one may add eggs, gruel, 
cereals, fresh green vegetables, stewed fruits. Much sugar 
is forbidden, as it is apt to cause fermentation, fats too, often 
give rise by fermentation to the formation of acetic, lactic 
or butyric acids and should be avoided. 

After a month of this diet Osier recommends a return to 
the milk period again for a time, alternating with the addi- 
tional diet as indicated. Of course all the foods that belong 
to the irritating class are to be permanently studiously 
avoided. Besides those already mentioned one must in- 
clude meat or strong meat broths, neither of which should be 
taken for a long time in order to keep the production of urea 
down to the minimum. 

Occasionally the milk may be advantageously given in the 
form of the Karell cure, particularly if the cirrhosis is compli- 

1 Osier's Modern Med., vol. iii, 444. 

2 Ro!leston: Diseases of Liver, p. 297. 

3 Herter Lectures on Chem. Path., 1902, p. 88. 

27 



418 DISEA SES OF A CCESSOR Y DIGESTI VE GLA NDS 

cated by ascites. The low salt content of this diet (1.3 gm. 
per day) acts as one of the salt-poor diets does in nephritis 
and often helps in the removal of the fluid, at least in part. 

Einhorn recommends duodenal feeding in cirrhosis on 
account of its sparing the portal congestion; reports on its 
usefulness are, however, meager. 

Biliary Cirrhosis. — Here we have more often an extension, 
via the bile ducts, of a direct infection of the biliary system, 
the cause often originating in the intestine. 

The diet is much the same as that recommended for por- 
tal cirrhosis, although the milk diet may not need to be so 
rigorously or so long continued. Constipation must be 
especially combated and is best managed by a morning 
saline laxative. After the milk period of feeding is over we 
may give sago, zweiback, rice, potato, fish, chicken, etc., 
avoiding all the irritants as in all other diseased states of the 
liver. 

Fatty Liver. — Since the chief cause of fatty infiltration of 
the liver is the excessive ingestion of alcohol or fats, the 
natural recommendation for prophylaxis would be to take less 
or none of either. The fatty degeneration of the liver will 
hardly be affected by diet, except as it may modify the acute 
infection which is the cause of the degeneration. 

As a matter of fact fatty infiltration and degeneration 
usually go hand in hand; one or the other predominating, 
depending upon the etiological factors. 

When one has a well-developed case of fatty liver due pri- 
marily to infiltration, it is necessary to oversee the patient's 
diet with great care. If the individual is obese it will be 
necessary to institute a reduction diet cure combined with 
suitable exercises (see Obesity). In this way a certain 
amount of excess fat can be removed in the general course 
of reduction and with the improvement in the patient's 
general condition in consequence of this it is also probable 
that the fatty infiltration will become less marked unless it 
has already gone on until the liver tissue has become very 
fat, as occurs in the more severe cases. 

Overeating and alcohol are especially to be forbidden, 
although this is true, too, of all the conditions already 
described. Fat food must be interdicted and only a moder- 
ate amount of carbohydrate allowed. In hot climates a 
vegetable diet with milk is particularly recommended. 
Where there is fever, meat must be restricted, otherwise it 
may be allowed in moderation, 1 and all the lighter proteins 
are well borne, as fish, eggs, milk and cheese, if not too rich. 

1 Quincke, Hoppe, Seyler: Die Krankheit d. Leber, p. 122. 



DISEASES OF LIVER AND GALL-BLADDER 419 

As has been already said, when the fatty liver is part of a 
general adiposis the patients must be treated as for obesity 
with the hope that much of the excess of fat can be gradually 
removed as the patients return more nearly to their normal 
condition and weight. 

Acute Yellow Atrophy of the Liver. — Since the admitted 
cause of this condition is a toxemia, not always due to the 
same agent, the treatment consists in prophylaxis so far as 
possible. Any form of jaundice, therefore, particularly that 
occurring in a pregnant woman, should always be viewed 
with suspicion. 

When the condition has been diagnosed the diet plays a 
not inconsiderable part in the treatment and since there is 
apt to be an acid intoxication present the giving of cereal 
gruels other than oatmeal is important, which with milk 
should form the basis of the diet. The drinking of a large 
amount of an alkaline water or even plain water, to which 
sodium bicarbonate is added or not, is recommended by 
Kelly. 1 

Amyloid Liver. — The etiological factor in this disease is 
some focus or foci of chronic suppuration, and the diet 
should be constructed with an idea of increasing the food 
consumption to the maximum, compatible with health, in 
order most successfully to combat the chronic infection, 
which should, of course, be treated surgically if possible. 
All fat foods, such as cream, butter, fat meats; concentrated 
carbohydrate foods, as breads, cereals, macaroni; sugars and 
honey are especially good. The protein of the diet should 
be increased to approximately 120 gm. if the patient can take 
this amount, for combined with exercises this amount of 
protein will favor the formation of tissue and thus increase 
the active protoplasm. 

Cholelithiasis. — From the dietitian's point of view nothing 
can be done to aid in the removal of gall-stones when already 
formed, although much has been written on the possibility 
of dissolving gall-stones in situ. Their partial disintegra- 
tion and occasional complete disappearance does take place 
experimentally, when gall-stones are placed in a dog's blad- 
der, either in its normal condition or when an experimental 
inflammatory condition has been produced in the gall-blad- 
der, but this is very different from the conditions under 
which the stones form in the human subject and when formed 
seldom, if ever disappear spontaneously. This does not 
mean that the gall-stones may not "go to sleep" so to speak, 
and remain quiescent for years or permanently, as this often 

1 Osier: Modern Medicine, 1st. Ed., vol. iii, 477. 



420 DISEASES OF ACCESSORY DIGESTIVE GLANDS 

happens in the experience of every physician. While diet 
has little or nothing to do with the disappearance of stones 
when already formed, it has much to do with their formation 
in the first place, and still more to do with their recurrence 
after operation, for statistics show that a fair number of 
patients in whom the gall-bladder is not removed at time of 
operation suffer from recurrence of gall-stones. 

Naunyn, Kehr, Aschoff and others regard the formation 
of gall-stones as merely an incident in disease inwhich infection, 
bile stasis and inflammatory manifestations are the principal 
factors 1 and it is against these factors of disease that dietetic 
treatment should be directed, rather than against their 
results. Dietetic indiscretions, long continued, that lead to 
catarrh of the stomach, duodenum and gall-bladder tend to 
produce gall-stones indirectly by affording means for the 
access of bacteria 2 to the biliary tract, so that little need be 
said to press home the importance of diet as a preventive 
measure. 

While a large majority of gall-stones are formed of choles- 
terol, almost every one has at its center a bacterium of one 
sort or another, so that infection is perhaps the first and 
chief necessity in the production of stones. Lime salts are 
frequently superimposed on the cholesterol stones, as well, 
and bile pigments, particularly bilirubin, form part of many 
stones. 

Prophylactic or Postoperative Diet. — There are no new 
principles involved in choosing a diet to prevent reformation 
of gall-stones, and with certain exceptions it is probably as 
much a matter of the quantity of food ingested as the qual- 
ity. These exceptions will, of course, include all foods or 
drinks that tend to produce gastro-intestinal catarrh or those 
which have a direct effect on the liver by virtue of their 
intrinsic irritating character and the fact of their being 
carried directly to the liver by the portal system. Such 
foods and drinks have already been spoken of in connection 
with portal cirrhosis and include condiments as peppers, 
mustard, curry, spices, salty foods, alcohol in all forms and 
very hot foods or drinks and ice-water in large amounts. 

Meats. — Only easily digestible meats should be taken and 
"high" meats, pork, fatty meat and fish, such as goose, duck, 
mackerel and blue fish should be avoided. 

Fats. — Some dietitians condemn the use of all fats, but 
there does not seem to be any reasonable basis for such com- 
plete prohibition. Fat is an essential food element and is a 

1 Anderson: Canada Med. Assn. Jour., 1914, iv. 
2 Osier: Modern Medicine, iii, 444. 



DISEASES OF LIVER AND GALL-BLADDER 421 

necessary part of any mixed diet. What should be avoided 
is fat that is particularly indigestible, such as all those that 
melt only at a higher temperature than the body, e. g., 
mutton fat, salt fat, as bacon or pork, or excess of even 
simple fat is to be avoided. There is no objection to sweet 
butter, cream in moderation and vegetable oils and meat 
fat in great moderation that has a low melting-point, as 
beef fat. 

Carbohydrates. — Sugar should be restricted as liable to fer- 
ment and cause indigestion; pies, preserves, candy, rich 
cakes, syrup, etc., are all to be avoided. Aside from these 
restrictions one may eat almost anything provided it is not 
in excessive amounts sufficient to cause overloading of the 
digestive tract. 

All means to stimulate the flow of bile are especially indi- 
cated and to this end it is often better to give five small meals 
a day, than three larger ones, as each time food is taken, 
bile is expressed from the gall-bladder. 

Vegetables and Fruit. — All vegetables that do not ferment 
are allowable but the cabbage family, radishes, horse-radish 
are barred, also according to Tibbies 1 peas, beans, lentils and 
carrots as containing phytosterol, a vegetable form of choles- 
terol, the principal constituent of gall-stones. Fruits that 
are not too sour may be taken, but they are possibly better 
borne stewed with a little sugar. 

Exercises. — Exercises that tend to stir up the liver are all 
good, such as horseback riding and calisthenic exercises 
which include bending and compression of the liver area. 

Alcohol. — As already stated patients are better off without 
any alcohol whatever, but when it is insisted upon, they may 
take light Rhine wines, well diluted with an alkaline water, 
such as Vichy, and only with meals and in the greatest mod- 
eration. Not over 3 or 4 ounces of wine with one meal a day. 
Spirits, all forms are particularly bad as tending to produce 
a catarrh of the stomach and intestines, besides irritating 
the liver cells. 

Acute Cholecystitis and Colic. — During the attack usually 
nothing can be taken by mouth often not even water. Later 
when the stomach is not rebellious, one had best begin with 
milk diluted with an alkaline water, Vichy, soda or Apolli- 
naris. This should be kept up until all signs of inflammatory 
reaction have disappeared, although possibly thin cereals 
may be begun awhile before this, but milk should form the 
basis of the diet. Later solid food may be taken as outlined 
in other hepatic conditions. Here again a mild saline cath- 

1 Food in Health and Disease, p. 384. 



422 DISEASES OF ACCESSORY DIGESTIVE GLANDS 

artic should be given in the morning regularly for a time as 
recommended for catarrhal jaundice and to which a small 
amount of sodium salicylate may be added to promote the 
flow of bile; possibly the sulphates are best for this laxative 
purpose. 

In all forms of gall-bladder disease from cholecystitis to 
stone there is great necessity for drinking water very liber- 
ally, and patients should be given a definite amount of water 
to take in the twenty-four hours. 

PANCREATIC DISEASE. 

The point at which disease of the pancreas touches diet- 
etics is when the function of the gland is interfered with, so 
that we find an insufficient, deficient or excessive secretion. 
Heretofore it has been possible only to arrive at abnormal 
conditions of the secretion by watching the effects on food 
digestion, and numerous tests sprang up for determining 
which element of the secretion was deficient, so we had tests 
for tryptic digestion, that for pancreatic amylase and pan- 
creatic lipase. Since the introduction by Einhorn of the 
duodenal tube it is possible in many cases to obtain samples 
of pancreatic juice, sufficiently large for chemical analysis 
and to make satisfactory biological tests of its digestive 
capability. Einhorn and Rosenbloom 1 have done this very 
satisfactorily from a clinical stand-point and have deter- 
mined the composition of the normal pancreatic juice. There 
are variations in the secretion of a purely functional nature, 
as well as variations due to pathological changes. Defi- 
ciency of trypsinogen produces azotorrhea or meat indiges- 
tion, lessened lipase a steatorrhea or fat indigestion, and 
diminished amylopsin results in carbohydrate fermentation. 
When we have a new growth or interference with the pan- 
creatic internal secretion, pancreatic diabetes is the result 
with an alimentary glycosuria and hyperglycemia. 

Still another result of pancreatic and intestinal distur- 
bance is the production of that curious condition of arrested 
development known as infantilism, where the subjects 
develop mentally, but physically they do not increase much 
in size, although they may take on the adult characteristics. 
Besides a disturbance in pancreatic secretion in infantilism 
the intestinal flora is an entirely abnormal one. 

Acute Pancreatitis. — In acute pancreatitis there is usually 
little time to resort to diet for the patients are for the most 
part in shock. If they survive this initial period, then they 

1 Arch. Int. Med., December, 1910. 



PA NCREA TIC DISEA SE 423 

may continue to improve, in which case diluted milk, gruels 
and other liquids (without meat stock) and farinaceous foods 
generally may be added to the diet, and later chicken and 
soft vegetables. 

Chronic Pancreatitis, — Here the pancreatic secretions may 
be disturbed in any one of the directions indicated, i. e., 
there may be a failure or diminution of the trypsinogen, 
steapsin or amylopsin with resulting characteristic evidences 
of this failure in the so-called pancreatic indigestion. It is 
here that we are apt to encounter the cases of marked stea- 
torrhea characterized by stools with yellow masses of fat, 
fluid or semisolid, which if not accompanied by jaundice 
may amount to an average loss of 64 per cent, of the ingested 
fat. If there is mild jaundice the loss will be greater (72 
per cent.) and if the jaundice is marked and bile is completely 
shut off the loss will amount to 87 per cent. 1 Naturally 
when this condition obtains the diet must be made up 
almost exclusively of carbohydrate and easily digestible pro- 
tein, although by giving artificially prepared pancreatic 
extract it is usually possible to give a minimum amount of 
simple fat. In this form of pancreatic deficiency sweet- 
breads, lean meats, cheese, fowl, breads, macaroni, baked 
potato, rice and other cereals, sugars, soft vegetables and 
fruits only if there is no accompanying diarrhea, which is 
regularly present in the cases of extreme deficiency of steapsin. 

When there is a diminution or absence of trypsinogen we 
find azotorrhea present, in which condition striated muscle 
fibers can be found in the stools, a condition often associated 
with marked intestinal putrefaction of protein and with an 
accompanying indicanuria. Under these circumstances the 
diet should be largely carbohydrate with some fat in the 
form of butter, eggs and thin cream. Milk will be fairly 
well digested if the gastric secretions are approximately 
normal, or failing this the deficiency in trypsinogen may be 
supplied again by the pancreatic extract. Cream cheese 
may also be used to supply protein, besides the vegetable 
protein. All forms of farinaceous foods may be used in large 
amounts together with soft green vegetables and stewed 
fruits. In fact almost any food low in protein will be well 
digested. 

When the amylase is deficient in the pancreatic secretion 
marked fermentation of the stool will take place in the fer- 
mentation tube, so that here it is necessary to reduce the 
starches to the minimum and give them preferably malted or 
with a diastatic ferment to compensate for the loss of the 
natural ferment. 

X T. Brugsch: Lehrbk, klin. Untersuch. Method., p. 371. 



424 DISEA SES OF A CCESSOR Y DIGEST I VE GLA NDS 

In the condition of achylia of the stomach the starch in 
moderate amount will be digested by the ptyalin of the 
saliva, but with normal or increased gastric acidity, this is 
soon stopped and the starches pass into the intestine im- 
perfectly dextrinized. 

In selecting a diet for these cases any of the simple fats 
and protein foods may be given, but the carbohydrates best 
tolerated are those partly malted, as malted breakfast food, 
toast dried to a brown crisp, dry and partially malted cereals 
in flakes. Next best are fine cereals well-cooked, such as 
farina, wheatena, cream of wheat and well-boiled rice. 
Potato and breads are best left alone unless each meal is 
followed by some artificially prepared diastase and this may 
be necessary even with the carbohydrates already partially 
prepared by previous malting. 

Where the internal secretion of the pancreas is disturbed 
and we have a glycosuria the diet must be in accordance with 
the dietary principles recommended for diabetes mellitus, 
although here, too, artificial diastase helps in the starch 
digestion. But these cases are practically diabetics and 
should be so treated. 

In carcinoma, cyst or other pancreatic disease the diet 
should be chosen with reference to the functional integrity 
of the gland or the lack of certain of the digestive elements, 
as we have just seen in chronic pancreatitis, 



CHAPTER XXIV. 

DIET IN DISEASES OF THE SKIN. 

In order to prescribe a rational diet for any disease it is 
necessary to understand its etiological factors, at least to 
some extent. It is therefore unfortunate that thus far there 
are very few skin diseases in which any definite general meta- 
bolic changes are known. With the skin lesions caused by 
parasites, irritants, etc., we have as dietitians no concern, as 
food plays no part either in their production, course or cure. It 
has long been the custom to place the blame for many skin 
lesions at the door of the digestive canal and in some 
instances rightly, though often without adequate scientific 
basis of fact,. to be sure, and only on the strength of clinical 
evidence. There is therefore a vast field as yet inadequately 
explored, and until painstaking nutritional studies are made 
on more diseases, we can for the most part only prescribe 
diets on the basis of bedside experience. The dermatoses 
due to disturbed metabolism may be divided as Johnson 1 
says into: 

i. Disorders due to derangement of digestion. 

2. Disorders of intermediary nitrogen metabolism. 

3. Disorders due to anaphylaxis. 

The alimentary eruptions von Noorden 2 divides into: 

(a) Acute alimentary eruptions from dietetic causes, such 
as the urticarial erythemata of the vesicular and bullous 
types, which may be produced by strawberries or other 
fruits, asparagus, cabbage, fish, cheese, spices and in some 
even by fresh eggs. 

(b) The chronic alimentary eruptions, for example, pella- 
gra, ergotism and scurvy, although we believe now that 
both pellagra and scurvy are dependent for their production 
in some way on lack of vitamines. 

Of the disorders of digestion which give rise to eruptions 
we have changes in gastric secretion, notably hyperacidity, 
which give rise to vasoconstriction of the skin vessels, as 
seen in loss of hair. 3 

In disorders of intermediary nitrogen metabolism John- 
son found that the N partition gave evidence of disturbance 
shown by a " decrease of urea and a corresponding increase 

x Jour. Cut. Dis., 1912, p. 136. 

2 Path, of Metab., vol. iii, 759. 

3 Quart. Jour. Med., 1915, viii, 156. 

425 



426 DIET IN DISEASES OF THE SKIN 

of rest nitrogen, and when this was marked, symptoms could 
be looked for." A change in the nitrogen partition occurs 
in eczema, prurigo and dermatitis herpetiformis, particularly in 
the beginning of the attack. It is not all sure, however, 
that the lack of nitrogen balance is merely a symptom. In 
the class of dermatoses due to anaphylaxis we have a definite 
protein hypersensibility in certain individuals which results 
in such conditions as urticaria and angioneurotic edema. 
These diseases are of course of alimentary origin, as already 
explained, but they may occasionally occur from parenteral 
protein intoxication. 

Tidy, on the other hand, concludes from a study of nitro- 
gen metabolism in dermatoses, that : 

1. Changes in the nitrogen excretion in various derma- 
toses are the result of the condition of the skin and are not 
connected with the cause of the disease. 

2. Retention of nitrogen is apparent, not real, and is 
accounted for by the abnormal excretion of nitrogen by the 
skin. 

3. Changes in the nitrogen excretion may precede the 
eruption and it is possible that these may survive it. 

In spite of these findings Tidy suggests that a low protein 
diet is worth a trial in dermatoses which are associated with 
disturbances of nitrogen excretion. 

Although authorities differ in their findings, enough has 
been said to show that the storm center is about the metab- 
olism of the protein molecule and that carbohydrate and fat 
enter very little into the discussion of etiology, except in so 
far as they may give rise to some form of gastro-intestinal 
disturbance more from quantity than quality. One notable 
exception to this is, that according to some authorities, fat 
stands in the first place in the etiology of eczema, particularly 
in infants. The relation of diet, therefore, to diseases of the 
skin is undoubtedly, in many instances, a most intimate one, 
but too little has yet been done, with one or two possible 
exceptions, to place the question on a basis of established 
fact. 

PSORIASIS. 

This is one disease of which considerable study has been 
made by Shamberg 1 and his collaborators, to determine the 
metabolic changes. In their investigations the complement- 
fixation test was not found to be positive, nor was any organ- 
ism to blame, but a marked nitrogen retention was found 
throughout the period of the experiment and it was felt that 

x Jour. Cut. Dis., October, 1913, p. 708. 



PSORIASIS 427 

a definite relationship between the amount of nitrogen in the 
food and the cause of the disease was established. The 
corresponding clinical evidence corroborated this, as the 
patients improved on a low protein diet and became worse 
on a high protein allowance; this finding was verified in a 
number of patients. The retention 01 nitrogen in these 
cases resembled that seen in convalescence and in one in- 
stance amounted to 4.8c) gm. nitrogen per day. Curiously 
enough, however, these patients suffer from what Shamberg 
calls "nitrogen hunger" and patients with "severe psoriasis 
present a state of remarkable protein undernutrition." 
This is because the retained protein goes into making the 
psoriatic scales which are almost pure protein. The success 
of the low protein diet in these cases is due to the fact that 
we can reach the point in diet at which the protein goes only 
to the vital organs at the expense of the scales, so that the 
latter do not grow. The amount of protein is therefore 
only sufficient to cover the wear and tear of the body and 
leaves nothing to supply the rapidly growing scales. Sham- 
berg ends his conclusions by saying that "the low nitrogen 
diet has a most favorable influence on the eruption of psor- 
iasis, particularly when it is extensive, almost to the point 
of the disappearance of the eruption." A high protein diet 
on the other hand, has an unfavorable influence on the 
disease and commonly causes its extension. The practical 
application of these findings in choosing a diet is therefore 
plain; one should keep the protein down to the low level 
determined by Chittenden: 45 to 60 gm. (ij^ to 2 oz.) of 
protein per day or for a short time on even less, of which the 
following menus are examples. 

Low Protein Diets in Psoriasis. 

Grams. Ounces. 

Bread 245.5 8 

Sugar 63 . o 2 

Coffee (breakfast) 210.0 7 

Custard 76.0 2]A 

Milk. 250.0 S}4 

Coffee (lunch) 125.0 4 

Potato 150.0 5 

Lima beans 80.0 2 2 /% 

Coffee (dinner) 210.0 7 

Apple dumpling 131.0 4J/J3 

Candy 27.0 

Total nitrogen in food, 8.83 grams = 55 gm. protein. 

Fuel value of the food, 1929 calories. 



428 



DIET IN DISEASES OF THE SKIN 



Grams. Ounces. 

Bread 164.0 5^ 

Sugar 89.0 2% 

Coffee (breakfast) 210.0 7 

Sweet potato 1350 4^ 

Quince preserve 73 -O 2}/^ 

Apple turnovers 11 8.0 4 

Coffee (lunch) . 310.0 ioj^ 

Potato 175.0 6 

Peas 80.0 2% 

Apple pie 141. 5 4^ 

Coffee (dinner) 210.0 7 

Total nitrogen in food, 7.31 grams = 45 gm. protein. 
Fuel value of the food, 2057 calories. 

Grams. Ounces. 

Bread 221.5 7^ 

Sugar 77.0 2% 

Banana ..... 92.5 3 

Coffee (breakfast) 210.0 7 

Baked potato 165.0 5>£ 

Applesauce 114. o 4 

Coffee (lunch) 210.0 7 

Succotash 75 -O 2^ 

Mashed potato . . 200.0 6}4 

Chocolate cake 80.0 2% 

Ice-cream 73 .0 2% 

Coffee (dinner) 210.0 7 

Total nitrogen in food, 7.63 ounces = 47 grams protein. 
Fuel value of the food, 2065 calories. 1 

Foster's experience, that he could get much more rapid 
results in psoriasis by making the patiets vegetarians, is 
easily explained on the basis of facts already submitted. 

ECZEMA. 

This skin disease is of great importance, as it constitutes, 
according to Bulkley, one-third of the entire number of skin 
diseases and its dietetic management is at times exceedingly 
satisfactory. Eczema is caused by a number of different 
factors but in many it can be traced to dietetic faults of (1) 
eating too much; (2) insufficient food; (3) improper food; 2 
(4) Hypersusceptibility to certain proteins. 

1. In those who eat too much food the cutaneous glands 
are constantly overstimulated, resulting in a change in the 
secretions, and as Thompson says, after 'long irritation the 
skin finally succumbs to a definite eruption. 

2. When one is run down from insufficient food, skin 
lessions are more apt to develop, particularly since with 
malnutrition from poverty there are usually added unclean 
personal habits. 

1 Chittenden: Physiological Economy in Nutrition, p. 62. 
2 Thompson: Practical Dietetics, p. 685. 



ECZEMA 429 

3. Everyone knows the effect of improper foods, those 
rich and indigestible, and in persons ingesting such foods 
eczema is prone to develop. 

4. Certain infants are susceptible to particular proteins and 
give a skin reaction thereto which is really of an anaphylactic 
nature. 1 

In adults as well as in children, one or more of these causes 
may be operative, and a careful scrutiny of the patient's 
actual dietary is necessary before coming to a definite con- 
clusion as to just which causes are at fault in a given case. 

Acute Eczema. — The consensus of opinion is that a limited 
and simple diet is indicated in acute eczema and in fact this 
rule is applicable to all acute inflammatory skin lesions. 
Such a restriction is best accomplished by placing the pat- 
ients either on an exclusive milk diet or with cereals, bread, 
butter, and fresh green vegetables or on the so-called rice 
diet which Bulkley recommends from laige experience. 
Bulkley's diet consists exclusively of rice, bread and butter 
and water for at least five days, after which other foods are 
gradually added. The rice should be thoroughly cooked 
for from thirty to sixty minutes in water, not with milk. 
It can be dried out a little after cooking if it is more palatable 
in this form. Butter and salt are to be eaten on the rice, 
which should be taken very slowly, accompanied by thorough 
mastication. The bread should be stale. According to 
Bulkley the rationale of this diet lies in the fact that acute 
eczematous manifestations are due to retained nitrogen 
waste products, and giving a diet that is of low nitrogen con- 
tent, allows the kidneys to excrete the retained matter, and 
when this is accomplished the acute stage of the eruption 
comes to an end. 

At the end of five days it is advised to return gradually to 
a mixed diet, taking first one regular mixed meal at middav 
and the rice diet morning and night. 

If this is successful a light breakfast is given, such as 
cereal with butter, eggs and bacon and possibly a little weak 
tea or coffee, 2 soft green vegetables, farinaceous puddings, 
whole meal bread, eggs, milk, chicken, fresh fish are then 
added. Many authorities forbid fruit in any form while 
others allow it stewed without sugar and still others fresh, if 
ripened nearby and not picked green. 

Chronic Eczema. — In chronic eczema the question as to 
"too much," "too little" or "improper food," comes up, in 
a way, for consideration much more than in the acute form. 

1 C. H.Smith. 

2 Bulkley: Diet and Hygiene in Diseases of the Skin, p. 70. 



430 DIET IN DISEASES OF THE SKIN 

Here much can be done to bring about a favorable progress 
of the disease by cutting down the food of the glutton, feed- 
ing up the poorly nourished and regulating the diet of those 
who habitually eat indigestible or improper foods. 

Among articles of food that should not be touched by these 
patients are spices, condiments, alcohol, fried foods, rich 
gravies, pastry, sweets, cake, cheese, salt food, ham, nuts, 
corned beef, salt pork, much meat and meat soups, salads 
and twice-cooked meats and curries. 

The low (Chittenden) level of protein is advisable for 
those who habitually overeat. These prohibitions also 
hold for the " after-diet" in acute cases. 

Eczema in Nurslings. — Here the dietetic and hygienic 
faults are the mother's, and attention to her intake, exer- 
cise, and bathing, will often result in the relief of the infant's 
eczema. There are commonly two varieties seen : 

1. In overnourished, fat babies who have shown evidence 
of eczema since birth. 

2. In those babies who have previously thriven, but who 
develop gastro-intestinal trouble and eczema, seen espe- 
cially when they are weaned and put on an improper milk 
mixture. 

In the first group the mothers are usually found to overeat 
or take too much alcohol and too little exercise. In the 
second group the babies' stools indicate indigestion, which, 
if rectified results in a cure of the eczema. Finckelstein has 
obtained good results by feeding nutrose (casein prepara- 
tion) before each feeding or by giving buttermilk twice a day 
with some additional carbohydrate. 1 In artificially fed child- 
ren with eczema Holt advises giving food moderately high 
in fat and low in protein and if not successful he reduces both 
fat and protein. In some instances, according to C. M. 
Williams, it is advisable to withdraw milk entirely from the 
diet and substitute wheat jelly, thin gruels, beef juice and 
eggs. Also careful attention must be given to the regulation 
of the times of feeding. Still other children are benefited 
as soon as they can be placed on mixed feedings, this is 
particularly true in the chronic form. It is also true here, 
as in adults, that those children who are overfed will do 
better if the food is reduced both in quantity and quality 
and, vice versa, the undernourished fed more liberally. 

Meyer found that children with chronic eczema showed 
salt retention which in turn leads to water retention predis- 
posing to eczema. On this basis Finckelstein fed a salt- 
free milk diet with high protein and carbohydrate with good 
results. 

1 Lyman: Arch. Ped., 1915, xxxii, 175. 



ACNE ROSACEA 431 

This salt-free milk is prepared by removing the salts by 
washing the casein in water then mixing the curd with four- 
fifths water and one-fifth whey with the addition of 40 to 50 
gm. of salt-free carbohydrate. This is known as "eczema 
soup." 

This is not applicable to all cases, but does best in fat 
babies with a moist, " weeping, " impetiginous eczema, when 
protein digestion is poor, as shown by curds and undigested 
stools. 

Reducing the percentage of the protein in the food will 
often result in clearing up the eczema. 1 In certain cases 
cutting out all sugars and carbohydrates and putting the 
children on a skimmed milk diet, does much to clear up the 
disease — this of course is almost another way of saying to 
starve the children moderately. Of course if the eczema is due 
to protein susceptibility no measure will be definitely efficient 
until the offending protein is discovered and eliminated 
from the diet. This diagnosis is made by testing the skin 
reactions as is done in asthma and urticaria. 

Since there is apt to be a very high urinary acidity in all 
chronic cases of eczema this should be rectified by giving 
large amounts of water plain or alkaline. 

The dietary regulations given are good so far as they go 
and in some instances are sufficient for a cure, but almost 
all cases require local treatment as well. 

ACNE ROSACEA. 

The underlying condition in acne rosacea is a vasomotor 
instability affecting particularly the blood supply of the skin 
of the nose and cheeks, resulting in abnormal flushing of these 
parts of the face. 2 Such a condition can be brought about 
temporarily, even in normal persons, by hot drinks as soups, 
tea, etc., particularly in an overheated room. Alcohol is of 
course the greatest etiological factor in the production of 
chronic rosacea, although it by no means follows that all 
chronic cases can be traced to this as a cause. The alco- 
hol acts largely through the gastritis which it causes; gastric 
hyperacidity from other causes being also frequently respon- 
sible for the production of acne rosacea. Chronic indiges- 
tion, gastric or intestinal, associated with the putrefaction 
of animal protein and often accompanied by high percentage 
of indican in the urine, acts much in the same way and must 
be kept in mind when prescribing a diet. 

1 Lyman: loc. cit. 

2 G. T. Jackson : Diseases of the Skin. 



432 DIET IN DISEASES OF THE SKIN 

The proper diet in rosacea is one from which are excluded 
all the known etiological factors, e. g., alcohol, hot tea, coffee, 
soup, spices, condiments, fried food, rich sauces, gravies, 
made-over dishes, pastry, heavy sweets, rich cake, and every- 
thing known by the individual to be a possible cause of 
gastro-intestinal indigestion. Patients should themselves 
notice the effects on the skin of any particular kind of food 
and learn to avoid those things which cause flushing. Of the 
greatest importance is the patient's general hygiene — baths, 
exercise, fresh air and water drinking — all of which is equally 
true in both acne rosacea and acne vulgaris. 

ACNE VULGARIS. 

In acne vulgaris the ducts of the sebaceous glands become 
closed, the plugs consisting almost entirely of epithelial cells 
with practically no foreign substances in them. A secondary 
staphylococcus infection is then engrafted on this, as the 
opsonic index is low to the staphylococcus, and results in 
pustulation or at least deep skin infection which may be only 
inflammatory, short of the production of pus. One' factor 
which probably favors the infectious element is the fact 
that in acne vulgaris the percentage of blood sugar is higher 
than normal. This form of acne is most frequently seen in 
young people at puberty and often disappears after a few 
years, although in some cases it is of exceedingly prolonged 
duration and taxes the ingenuity of the dermatologist. 

Where the patients are found to be excessive eaters, the 
quantity of food should be cut down and will often give relief, 
in some cases Jackson obtained the best results on an ex- 
clusive milk diet. On the other hand, when the acne is an 
accompaniment of malnutrition the patients should be 
liberally fed and everything done to improve their general 
health with consequent raising of their opsonic index. Tea, 
coffee and alcohol and all indigestible foods are forbidden. 
The amount of fat food should be limited and much the same 
restrictions insisted upon as indicated for acne rosacea. 
Williams 1 bars cheese, pickled food, sausage, cabbage, cauli- 
flower, griddle cakes, oatmeal and pastries, fresh bread and 
salads. Sweets are especially to be. forbidden as favoring a still 
further increase in the percentage of blood sugar, as well a 
large use of carbohydrates in general. 

ERYTHEMA. 

Erythema occurs in so many forms; simple erythema, 
erythema nodosum, multiforme, urticarial and hemorrhagic 
erythema — all of which are undoubtedly varying skin re- 
x Food and Diet, p. 337. 



PRURITUS 433 

actions to a variety of toxic ingesta, and it is difficult to know 
just where to begin a discussion of the subject from a dietetic 
point of view. Many persons learn early in life what foods 
will produce these effects and avoid them; again persons 
seem susceptible at one time to a certain food and not at 
another, so that to know just which form of food is respon- 
sible for a particular attack, often presents a problem of 
some difficulty. Where erythema multiforme is seen with 
urticaria it is probably of gastro-intestinal origin; if with 
purpura it is more apt to be due to some focus of infection or 
from a ptomaine toxemia. 1 Of course, it goes without say- 
ing that where a certain form of food is at fault that food 
should be avoided in future and the best method of treat- 
ment in addition to this advice is an initial thorough empty- 
ing of the digestive canal combined with the simplest sort of 
diet possible, in order to keep down intestinal putrefaction 
with its accompanying by-products, which are most often at 
fault. To this end a lactovegetarian and farinaceous diet 
is best and is usually promptly efficient in the transient forms, 
such as in acute urticaria, so often caused by fish or shell 
fish. In the more prolonged types, such as erythema multi- 
forme, it is often necessary to continue such a diet or at least 
a very bland and unirritating diet for a considerable length 
of time or until the eruption is entirely cleared up. 

In chronic urticaria we have a difficult problem and from 
a dietetic point of view an almost hopeless one unless we are 
fortunate enough by a process of exclusion to find some par- 
ticular food which is at fault. Testing the skin reactions 
with the different proteins sometimes shows which protein 
is at fault. Often, however, this is impossible and the most 
one can do in diet is to give simple and easily digested foods 
which, at least, will not increase the trouble by adding in- 
testinal indigestion. Since urticaria is thought by some to 
be always an anaphylactic phenomenon, the dietetic sugges- 
tions detailed under Asthma may prove most helpful in 
arriving at a proper dietary regimen. (See p. 323.) 

Erythema accompanying infection cannot, except second- 
arily, be influenced by diet, but at least nothing should be 
given to increase the skin irritation and avoidance of the 
class of so-called food irritants, such as condiments, spices, 
garlic, and alcohol, should be insisted upon. 

PRURITUS. 

Pruritus in any of its forms is an itching condition and may 
be due to many causes, ranging from an inherited irritable 
skin to that due to hemorrhoids or fissure, tobacco in excess, 

Anthony: Jour. Cut. Diseases, 1912, p. 112. 
28 



434 DIET IN DISEASES OF THE SKIN 

renal poisoning, diabetes, cold, ascarides, etc. 1 Most of 
these conditions, it will be readily seen, are not amenable to 
dietetic relief and yet we can do much to add to the discom- 
fort of an already irritable skin by an improper diet. 

When the itching is intense and the skin at all generally 
hot and inflamed it is a good plan to put the patients on a 
very bland lactovegetarian diet for a few days, as is true of 
all acute inflammatory skin lesions. Later avoidance of 
the stimulating class of foods such as condiments, is indi- 
cated; Jackson especially interdicts the use of alcohol, tea, 
coffee and tobacco ; some of the worst cases are seen in heavy 
smokers, and the condition is distinctly aggravated by even 
moderate smoking. 

"Prurigo and lichen urticatus are closely related to urti- 
caria and are accompanied by a highly susceptible vasomo- 
tor or sensory nerve system set in action by a variety of 
excitants which often elude one's investigation." 2 

In these conditions the diets suggested for rosacea and 
urticaria are useful. 



DERMATITIS. 

Dermatitis Herpetiformis. — Hardouin found retention of 
urea in the system just before the eruption in 8 cases, so 
that this is undoubtedly the local manifestation of a general 
metabolic disturbance and as retention of purine bodies 
probably lies in a causal relation to the disease it would be 
appropriate to prescribe a diet similar to that advised in 
gout or at least a very low purine diet, accompanied by effec- 
tual elimination through all the exits. Other investigators 
found normal urinary excretion and cultures and experi- 
mental inoculations of the liquid from the bullae negative 
and think much points to a deranged nervous system as the 
cause of dermatitis herpetiformis. During the acute stage 
the diet should be simply milk; tea, coffee and alcohol are 
forbidden — when the inflammatory condition has subsided 
vegetables, farinaceous foods and eggs may be added to the 
diet, returning gradually to a normal diet, excluding indi- 
gestible and purine-rich foods. (See Diet in Gout.) 

Exfoliative Dermatitis.— Probably the best results are 
obtained with a milk diet and in addition the use of colonic 
irrigations. Jackson (G. T.) advises flaxseed tea several 
times a day. After the acute stage is over a diet as in 
eczema is valuable. 3 

1 Jackson: Disease of the Skin, p. 450. 

2 Sutherland 's Dietetics. 

3 Thompson: Practical Dietetics, p. 685. 






HYPERIDROSIS 435 

Ferunculosis. — Ferunculosis should be treated dietet- 
ically like acne vulgaris and the same rules hold good. As it 
is especially prone to develop following severe illness during 
the period of convalescence, the indications are usually for 
a full nourishing diet, but simple withal. - The feeding of 
one or two yeast cakes daily is often of great service. 

Comedones.— Comedones are due to the blocking of the 
sebaceous gland ducts by a disordered secretion and are often 
accompanied by gastro-intestinal disturbances. The diet 
should conform to the actual digestive disorders present in 
an individual case and besides careful hygiene of the skin, 
elimination should be increased by copious water drinking. 

Hyperidrosis.— Since the sweating which accompanies 
hyperidrosis is caused by a vasomotor disturbance, general 
hygiene plays a part in the cure, with which must be included 
of course, and although there is no specific diet that is 
indicated, patients with hyperidrosis should avoid digestive 
risks and generally keep to a very simple diet. When the 
hyperidrosis is accompanied by obesity, uricacidemia or 
some nervous condition, these should receive their appro- 
priate hygienic and dietetic treatment. 



CHAPTER XXV. 
DISEASES OF THE GENITOURINARY SYSTEM. 

In attempting to discuss the food factor in nephritis, it 
must be kept in mind that the relation of diet to nephritis is 
two-fold — (i) in its causation role, about which we know 
little; (2) in its relation to rational treatment and dietetics 
of the disease, about which we know more but still too little. 
That food does often stand in an important role as the 
causation of nephritis must be admitted, although as yet 
we have but a glimmering of its true significance — but when 
we stop to think of the known drugs and foods which directly 
irritate the epithelium in greater or less degree, such as 
cantharides, turpentine, lead, arsenic, salicylic acid, mustard, 
peppers, the oil from garlic, onion and celery and numerous 
other substances — it is but a short cry to the possibility of 
repeated minimal irritation by foods less well recognized as 
renal irritants. The analogy of liver cirrhosis is sufficient 
for purposes of comparison, and while the liver is damaged 
in the attempt it makes to detoxify the irritating alcohol, 
hot sauces, etc., the kidney must run an equal risk in its 
excretion of most of the products of protein metabolism. 
That this is so has been increasingly evident and we have 
come to recognize still another form of renal irritant in re- 
peated anaphylactic shocks as demonstrated by Longcope 
by the injection into animals of protein after previous sensi- 
tization to these same proteins. After a large secondary 
dose of protein, acute degeneration of the renal epithelium 
is seen, or if less acute, one finds collections of round cells 
about the vessels and in the intermediate zone. If the 
process is long continued there is found a connective tissue 
increase and glomerular lesions. These changes are not 
confined to the kidney but are seen in the parenchyma of 
other organs. It can therefore be seen that a patient may 
unconsciously be constantly receiving mild, unfelt anaphy- 
lactic shocks from certain food proteins to which he is sensi- 
tive, with resulting renal changes. Again, any food that has 
a tendency to produce acid or to lower the alkaline reserve 
of the blood, will result in damage to the kidney. Among 
such foods may be mentioned excessive protein or fats, also 
inorganic acids. 

So presumably anything that reduces the alkaline reserve 
causes a damage to the cell protoplasm, which if constantly 

436 



NEPHRITIS 437 

repeated may well result in nephritis. Besides the lessened 
alkalinity of the blood, Auld suggests demineralization (cal- 
cium loss) and impaired metabolism as results of an acid 
excess. The subject of acidosis in nephritis is one about 
which much discussion and experimentation has been had. 
There is no doubt but that in the later stages of chronic 
nephritis there is a definite lowering of the alkaline reserve 
due to the accumulation of retained phosphates and there is 
no doubt but that this condition further cripples the kidney. 
The index of the acidosis is the concentration of carbon 
dioxide in the alveolar air as this corresponds with that in 
the blood. Dietetically, therefore, all foods that tend to 
reduce the urinary acidity are valuable in nephritis, provided 
there are no contra-indications from other view points. To 
this end, potatoes, apples, bananas, raisins, oranges, canta- 
loupe, sweet potatoes and carrots are especially good, 
for through them considerable amounts of the desired alka- 
line bases are gotten into the system. Blatherwick 1 showed 
that vegetables, fruits (the foregoing particularly) as a class 
on burning leave base or alkaline elements Na K Mg. Cal. 
while meat, fish, cereals (especially oatmeal), peanuts, plums, 
prunes and cranberries are not good as they cause acid pro- 
duction, the last four named, due to their benzoic acid con- 
tent. 

When we are in the presence of complications, such as 
edema or marked nitrogen retention, it may be necessary 
to modify the use of the foods especially recommended above 
but at least these suggestions apply strongly to the period 
in chronic nephritis before complications supervene and will 
surely help to put off their evil day. 

Gross overeating is undoubtedly a cause of kidney change 
probably of a fibroid nature, as we know that the same cause 
acts in producing arteriosclerosis, in which process the kid- 
ney shares, as do other organs. Taken then all together, 
there are definite ways in which food may act in the produc- 
tion of renal changes, although it is often a matter of great 
difficulty to decide in a given case just which cause is prim- 
arily at work, after the exclusion of the more usual causes of 
renal irritation, such as the infectious diseases, intestinal 
toxemia, focal infection, etc. 

The newer studies in kidney functions have brought to 
light many facts which have helped us to understand find- 
ings which were for so long obscure. Unfortunately they 
have not yet gone so far that we can classify all cases of 
nephritis, acute and chronic, to our entire satisfaction, but 

^rch. Int. Med. xiv, 409, 



438 DISEASES OF THE GENITO-URINARY SYSTEM 

enough has been accomplished by experimentation to justify 
certain therapeutic conclusions that have proven of great 
value. 

The factors which must be taken into especial consider- 
ation in dealing with the dietetics of nephritis have to do 
with the excretion of various substances derived from the 
digestion of foods, and the different behavior of the diseased 
kidney from the noimal kidney with respect to their elimin- 
ation. One starts with the premise that the healthy kid- 
ney can perfectly eliminate water, nitrogenous products of 
protein combustion, certain inorganic salts, notably sodium 
chloride, and organic compounds, which result from bac- 
terial activity. When one then begins to classify the cases 
of nephritis with respect to the individual's power to excrete 
these substances, one soon finds that they are almost never 
found to be of one simple type, since the structures of the 
kidney are all more or less involved, the excretion of one, 
two or all classes of constituents of normal urine may be 
interfered with, so that the kidney's behavior to the excre- 
tion of these various substances is not absolutely fixed. In 
spite of this fact, most of the cases may be grouped separately 
according as the excretion of one or another urinary constit- 
uent is chiefly interfered with. With experimental neph- 
ritis it is somewhat different; we can by means of various 
kidney poisons, artificially introduced into the animal's 
body, produce what is practically a pure type of tubular, glom- 
erular or interstitial nephritis. It has been by watching the 
elimination of the normal urinary constituents under one 
or another form of artificially produced nephritis that we 
know as much as we do in regard to the behavior of the 
kidney toward the normal urinary constituents with respect 
to their elimination. In this connection the effect of cer- 
tain foods on the behavior of the kidneys in eliminating dyes 
is the subject of much experimentation by Salant 1 and others 
with certain conclusions which are of great interest clinically. 

i. Small doses of tartrate of soda injected subcutaneously 
produced an inhibition of elimination of phenolsulphophtha- 
lein. When rabbits were fed on oats (acidophylic) it 
never went back to normal. 

2. Evidence of disturbed renal function was seldom ob- 
tained with much larger doses if the rabbits were on a diet 
of young carrots. Large doses of the tartrate gave some 
decrease in elimination but excretion went back to normal. 

3. If the tartrate was injected gradually in increasing 
doses, no impairment of function was noted even with very 

x Proc. Soc. Exp. Biol. Med., 1917-18, xv, 8. 



NEPHRITIS 439 

large doses (4 to 6 gm. per kilo) if carrots were used alone as 
diet. This was not so with a diet of oats. 

For a full discussion of the various diagnostic methods to 
determine the renal function founded upon the results of 
experimental nephritis, such as the sulphophenolpthalein 
test, salt test, potassium iodide test, lactose test, the determi- 
nation of the Ambard coefficient, water test and diet test 
days, the reader must be referred to any one of the newer 
editions of standard text-books on internal medicine. In 
order to know just which type of renal hypof unction a given 
case belongs to, some of these tests must be made and 
together with the history and clinical findings a fairly accurate 
idea can be obtained as to which function or functions of the 
kidney are disturbed and the diet arranged accordingly. 

Kidney Dietary Tests. — Water Excretion. — It is a simple 
matter to determine the water excretion by ordering a de- 
finite amount of water for the twenty-four hours and measur- 
ing the actual fluid intake and urinary output; thus if 1500 
c.c. (50 oz.) are taken and 1200 c.c (40 oz.) or thereabouts 
represents the output for twenty-four hours, the water ex- 
cretion is considered normal under oidinary conditions of 
temperature and humidity, as the 300 c.c (10 oz.) discrep- 
ancy between intake and output is lost by bowel, skin and 
lungs. 

Salt Excretion. — This is determined by noting the daily 
salt output both as to concentration (percentage of NaCL 
in the urine) and the total twenty-four-hour output on a 
known salt intake. For this purpose one of the salt-poor 
diets are used with a known salt content, to which a definite 
amount of salt is added after weighing. This should be 
done for several days and accurate daily estimations made. 
Normally the kidney should be able to concentrate chlorides 
up to 0.6 to 0.9 per cent, with a total daily excretion of 
practically the entire intake. 1 

Nitrogen. — The determination of nitrogen excretion is 
somewhat more difficult, but it can be done if the patient is 
placed upon a fixed nitrogen diet and the daily nitrogen 
balance determined. For this a well-equipped laboratory is 
necessary, while for the determination of water and salt 
excretion very little is needed in the way of apparatus. 
Schlayer's nephritic test day, as modified by Mosenthal, 

x Test for the Amount of Salt in the Urine. — Dilute 10 c.c. of urine with 900 c.c. 
of water and add one or two drops of 25 per cent, nitric acid. This mixture 
should be made alkaline with a 10 per cent, solution of sodium carbonate adding 
a few drops of a 10 per cent, potassium chromate for an indicator. Titrate with 
tenth-normal silver chloride solution. Every c.c. of silver solution used equals 
0.00583 gm. of sodium chloride. 



440 DISEASES OF THE GENITO-URINARY SYSTEM 



gives the information desired in the matter of water, sodium 
chloride and nitrogen excretion in the most convenient way 
as follows: 

Directions for Schlayer's Nephritic test Day 
(Mosenthal). 

Needed in the Ward. 

7 wide-necked bottles, each labelled. 

i bottle to hold iooo c.c. for night specimen. 

6 bottles to hold 500 c.c. for two-hour specimens during 

day. 
Salt in capsules, each capsule to contain 2.3 grams 
sodium chloride. 
Preceding day's diet should be "soft salt-free" with fluids 
limited to 1500 c.c. 

Test Day. — All food is to be salt-free, from diet kitchen. 
Salt for each meal will be furnished in weighed amounts 
(one capsule containing 2.3 grams, sodium chloride with 
each meal.) 

All food or fluid not taken must be weighed or measured 
after meals and charted. 

Allow no food or fluid of any kind except at meal times as 
directed. 

Note any mishap or irregularities that occur in giving the 
diet or in collection of specimens. 

Meals to be given at the following hours: 
Breakfast, 7.45 a.m. 
Dinner, n-45 a.m. • 

Supper, 4.45 p.m. 

No fluids between meals or during the night. 
Collection of urine during the day every two hours, and 
from 7.45 p.m. to 7.45 a.m. 

Empty bladder at the following times : 
No. of specimen: 7.45 a.m. discard 

1 9.45 a.m. save in separate bottle 

2 1145 a.m. 

3 1.45 p.m. 

4 345 p.m. 

5 545 p.m. 

6 7.45 P.M. 

7 7.45 P.M. tO 7.45 A.M. 

Label each bottle with period of collection, number of 
specimen and name of patient and send to laboratory. 
Breakfast, 7.45 a.m. — Chart food or fluid not taken. 

Boiled oatmeal, 100 grams; sugar, one-half teaspoonful; 

Milk, 30 c.c; 



NEPHRITIS 



441 



Two slices of bread (30 grams each) ; butter, 20 grams ; 

Coffee, 160 ex.; milk, 40 c.c.; sugar, one teaspoonful; 

Milk, 200 c.c. ; 

Water, 200 c.c. 
Dinner, 11.45 a.m. — 

Meat soup, 180 c.c; 

Beefsteak, 100 grams; 

Potatoes (baked, mashed or boiled), 130 grams; 

Green vegetables as desired; 

Two slices bread (30 grams each) ; butter, 20 grams ; 

Tea, 180 c.c; milk, 20 c.c; sugar, one teaspoonful; 

Water, 250 c.c. ; 

Pudding (tapioca or rice), no grams. 
Supper, 4.45 p.m. — 

Two eggs (cooked in any style) ; 

Two slices of bread (30 grams each) ; butter, 20 grams ; 

Tea, 180 c.c; milk, 20 c.c; sugar, one teaspoonful; 

Fruit, stewed or fresh, one portion. 
One capsule of salt with each meal = 3 x 2.3 grams. 

Findings in a Case of Chronic Hypertensive Nephritis. 



Time. 


Amount 
c.c. 


Sp. gr. 


Sodium 
Per ct. 


chloride. 
Total. 


Nit 
Per ct. 


rogen. 
Total. 


Approximate intake. 


7.45 to 9.45 
9.45 to 11.45 
11.45 to i-45 
1.45 to 3.45 
3.45 to 5.45 
5 . 45 to 7 . 45 


155 

97 

98 
255 

43 
325 


1013 
IOII 
IOI4 
IOIO 

1015 

IOII 










Fluids 1760 c.c. 
Salt 8 . 5 gms. 
Nitrogen 13.4 " 


Total day- 
Night 


983 
800 


1014 


.16 
•215 


1-57 
I.72 


•37 

.48 


363 

3.85 




Total 24 hours 
Intake 


1783 
1760 






3 29 

8-5 




7-49 
13-4 




Balance 


—23 




.... j+5- 21 




+ 5-91 





The figures show a negative water balance, but retention of both chlorides and 
nitrogen. 

In discussing the various urinary elements and their excre- 
tion, from the clinical point of view, we have a number of 
questions to be kept in mind. 

Water. — It was long thought that the giving of large 
amounts of water in any form of nephritis was the best thing 
one could do for the patient, with the idea of washing out 
the poisonous products of incomplete or even complete meta- 
bolism. Von Noorden differed from this view and showed 
that in certain cases the kidney could not eliminate water 



442 DISEASES OF THE GENITO-URINARY SYSTEM 

as well as it could other substances and the only effect of 
giving it in large amounts was to increase the edema, or if 
there was no edema, to overfill the circulatory apparatus, 
putting an extra strain on the heart and bloodvessels. 

In the normal individual there is a loss of water through 
skin and pulmonary excretion of approximately one-fifth of 
the intake, so that if a patient is given 2000 c.c. (66 oz.) of 
fluid, i. e.j 1500 c.c. (50 oz.) as fluid direct and about 500 to 
750 c.c. (16-25 oz.) in the food taken (which Mohr calculates 
to be about the amount of fluid contained in the ordinary 
diet) only 1600 to 1700 c.c. or there about will be excreted by 
the kidney (53 to 56 oz.) and the rest is lost in the ways 
already referred to. When in nephritis the amount excreted 
is still markedly less, then one may be sure that one is deal- 
ing with a nephritis which rinds difficulty in eliminating 
water, the unexcreted balance being held in the serous 
cavities, subcutaneous tissues or circulation. The question 
may well be asked, What then is the optimum amount of 
water to give in nephritis? To this no hard-and-fast rule 
can of course be given, but Mohr 1 found by experimentation 
that "in any form of nephritis the maximum amount of 
solids were eliminated if the patient passed from 1250 to 
1500 c.c (42 to 50 oz.) of urine. " Miller 2 further states that 
when the kidney is able to excrete the normal amount of 
fluid and there is no evidence of edema, 1500 to 2000 c.c 
(50 to 66 oz.) of fluid is quite enough to give in twenty-four 
hours. When there is difficulty in water excretion then the 
total amount of water best to give must be determined in 
accordance with that particular patient's capability as de- 
termined by daily measuring the intake and the urine, the 
doing of which is only a detail of general management. 

Salt. — In the consideration of the salt excretion, two 
classes of salts are to be considered; the chlorides, of which 
sodium chloride is the most important example, and the 
sulphates and phosphates, both of which latter behave much 
as the nitrogenous products do and not as the chlorides. If 
the patients have no subcutaneous edema the chloride 
elimination is normal even if the nitrogen elimination is poor. 
In other words, nephritis with edema invariably shows salt 
retention. 3 

Strauss puts the principles involved thus: "The human 
organism holds fast with extreme tenacity to the percentage 

x Beitrage Zur Diatetik der Nierenkrank. Ztschr. fur klin. Med., 1903, p. 

1377- 

2 Forchheimer's Therapeutics, vol. iv, 34. 
3 Ibid., vol. iv, 22. 



NEPHRITIS 443 

concentration of the fluids in sodium chloride." This is 
done by a regulating mechanism of which the kidney stands 
in the first rank. When more than enough salt is taken by 
a healthy person it is promptly eliminated and when the 
organism is starved, as in extreme vomiting, the output of 
salt in the urine is at once diminished in order to keep the 
blood concentration at about 0.6 to 0.9 per cent. 1 Strauss 
also reached the conclusion that the chloride retention in 
nephritis with edema was of renal origin and that withdrawal 
of salt from the diet (all but the necessary 1.5 or 2 gm. per 
day) was necessary for treatment. The three factors on 
which he based his views were: (1) that in unilateral neph- 
ritis lower chloride values are found in the urine from the 
diseased kidney; (2) in an exacerbation of the disease the 
value of sodium chloride excreted often falls off; (3) that only 
dropsies were helped by remedies which caused not only 
an increased water output but at the same time a polychlor- 
uria. Dechlorination according to the same authority con- 
sists of two elements: (1) a salt-poor diet; (2) salt elimi- 
nation from medicaments. 

The minimum of salt which is necessary to maintain the 
normal molecular salt concentration, as already stated, is 
about 1.5 gm. per day, but as it is almost impossible to con- 
struct a salt-poor diet with much less than this amount, 
there is no practical danger of actual salt starvation, provided 
there are enough calories in it to meet nutritional demands. 

Nitrogen. — When we turn to nitrogen elimination we find 
that in the mild types of nephritis the nitrogen elimination is 
delayed as compared with the normal person. This delay 
being caused (judging by experimental nephritis) by injury 
to the glomeruli. 2 Y\ nen one has to do with a more severe 
nephritis it is found that the nitrogen compounds are re- 
tained in the blood and tissues. These facts are of para- 
mount importance in prescribing definite amounts of pro- 
tein food, for with the more severe cases accompanied by 
nitrogen retention we must reduce the protein intake not 
only to the nutritional minimum but below this for a short 
time. 

Goodall 3 discovered that by placing chronic nephritics on 
a low protein diet the blood-pressure fell and on examining 
the blood of these cases that had been so dieted he found 
the non-protein nitrogen lowest and he therefore concludes 
that the general condition and bood-pressure were improved 

Strauss: Post Graduate, 1913, xxviii, 532. 
2 Manakow: Duetsch. klin. Med., April, 191 1. 
3 Boston Med. and Surg. Jour., 1913, clxviii, 761. 



444 DISEA SES OF THE GENITO- URINA RY S YSTEM 

when the end-products of protein metabolism in the blood 
were lowest. Frothingham and Smillie 1 tried diets in chronic 
nephritis of low, medium and high protein content and con- 
cluded "that in certain types of chronic nephritis the nitro- 
genous content of the diet should be carefully watched in 
order to prevent an increase in non-protein nitrogen in the 
blood. The exact effect of an increase in blood nitrogen 
produced by a high nitrogenous diet is not known at present, 
but presumably it is unfavorable to the best interests of the 
patient, since in some it increases their discomfort. A diet 
low in nitrogen content will frequently keep down to normal 
the non-protein nitrogen of the blood in chronic nephritis. 
In uremia the non-protein nitrogen is always high." To 
this last statement there are known exceptions. 

While the foregoing facts represent the general opinion in 
regard to kidney function and the influence of the various 
food-stuffs in the matter of excretion, another school of clini- 
cians, of whom Martin Fischer is perhaps the best known, 
take exception to almost all of these ideas and contradict 
flatly many of the foregoing statements in fact, most of 
them; thus for example Fischer recommends in all cases of 
nephritis that large amounts of water should be given even 
if apparently the patient is not excreting the normal pro- 
portion of the fluid intake. This is done to dilute the body 
acids so that they can be excreted, for "a kidney that is 
killing itself clearly needs water to rid itself of the poisons 
that are killing it." 2 Too much water he admits sometimes 
increases the swelling of the kidney and washes out valuable 
salts, but these objections are overcome by giving certain 
salts with the water, notably sodium chloride and sodium 
carbonate. 3 

If ordinary dried sodium carbonate is obtainable only one- 
third as much as the crystallized should be used. 

In regard to the use of the salt-poor diets Fischer and his 
school, as championed by Lowenburg 4 feel that the salt-poor 
diet may lead to albuminuria and nephritis which Fischer 
explains as being "due to the low salt content of the body 
occurring as a result of food without salt," which as already 
stated he believes washes out the salts naturally present. 
This salt starvation leads to renal acidosis and this to neph- 

^rch. Int. Med., 1914, xv, No. 2, 225. 

2 Martin Fischer: Nephritis, Cartwright Prize Essay, 191 1. 

3 The solution Fischer uses is: 

Sodium carbonate (crystallized) . 20 gm. ^ oz - 

Sodium chloride 14 gm. % oz. given by rectum. 

Water q. s. ad 1000 c.c. quart 

4 Jour. Am. Med. Assn., November 28, 1914, p. 190b. 



NEPHRITIS 445 

ritis as represented by albuminuria, cloudy swelling, casts 
and edema. 1 Lowenburg's conclusions in regard to NaCI 
based on Fischer's teachings are: 

1. Sodium chloride neither produces nor increases water 
retention in nephritics and non-nephritics. 

2. It is curative in cases of edema from any cause provided 
the kidneys are not too much damaged. 

3. When combined with alkalies and plenty of water it 
exerts a beneficial effect on the symptoms of nephritis. 

4. The best method of giving the salt is in an alkaline 
solution by rectum or intravenously (not hypodermically). 
' The answer to Fischer's objection, that a salt-poor diet 
causes sodium chloride starvation and low salt content in 
the body, is, that first, in severe nephritis the salt concentra- 
tion in the blood is above normal and second that it is practi- 
cally impossible as already explained, to give a salt-poor diet 
which contains less than 1 or 1.5 gm. sodium chloride, suffi- 
cient for the body needs for a considerable time, and at best 
a salt-poor diet of the lowest salt content is only a temporary 
expedient and a matter usually of not over ten to fourteen 
days. 

In dealing with the actual diets recommended for the 
various types of nephritis and their complications, the 
classification of renal diseases must necessarily be a simple 
one and a division into acute and chronic nephritis with or 
without nitrogen, salt, or water retention, one or more in 
combination, is about as far as we can go at present. The 
older method of ordering diet merely upon the basis of the 
supposed pathological changes in the kidney is no longer 
useful in the light of our present knowledge of renal function. 

Albuminuria. — Albuminuria being a symptom of renal 
irritation may be produced in a great variety of ways. It 
may be toxic in origin from chemical irritants that may have 
been ingested, e. g., turpentine, cantharides, mercury, etc., 
or from the toxemia arising from bacterial infection in the 
course of any of the acute or chronic infections, or as an 
early manifestation of primary renal disease or finally as a 
part of a general asthenia characterized by visceroptosis, 
small heart and ordinarily designated as an orthostatic 
albuminuria. 

When the albumin in the urine is a symptom of actual 
renal irritation, chemical or bacterial, it is necessary to treat 
the causal conditions by removal of poisonous materials 
from the food and to furnish such a dietary that no unneces- 
sary strain shall be put upon the renal epithelium. For this 

x Loc. cit. 



446 DISEASES OF THE GENITO-URINARY SYSTEM 

purpose a milk or lactofarinaceous diet is best, milk alone 
being used for the more serious cases and farinaceous addi- 
tions being made in the milder grades. When the albumin- 
uria is a part of a general acute or chronic infection, the 
diet must conform largely to the requirements of the partic- 
ular infection at fault, but in general the milk or lactofari- 
naceous diet fills the requirements perfectly and must be 
kept up as long as the signs of renal irritation persist. 

Where there are difficulties in the excretion of water, salts 
or nitrogen, as shown by edema or any evidences of acute 
uremia, it is often best to use either the Karell diet or one of 
the soft salt-poor diets, or with impending uremia a day or 
two of starvation, giving only water combined with hot 
packs, and colon irrigations, to relieve the internal congestion. 

In the ordinary milk diet, when that is applicable to these 
cases, we may order from 1500 to 2500 c.c. (3 to 5 pints) ot 
milk per day given in 180 to 240 c.c. (6 to 8 ounces) dosage, 
every two hours. 

As the albuminuria and other evidences of any inflamma- 
tory reaction subside and remain in abeyance, other articles 
of diet may be added — all farinaceous foods, vegetables, 
except those which contain irritating oils such as onion, 
garlic and celery; and lastly when things have settled back 
to what is practically a normal condition, a small amount of 
meat may be allowed. 

In the case of orthostatic albuminuria it is not necessary 
to diet strictly, for it has practically no effect on the quantity 
of albumin in the urine, all that can be done is to avoid an 
excess of any food or drink, particularly meat products and 
alcoholic beverages. 

Acute Nephritis. — In cases of acute nephritis from what- 
ever cause (except mercury poisoning, q. v.) the diet must be 
exceedingly sparing, and it is often best in acute uremia, pro- 
vided there is no water retention, to give nothing but water 
for twenty-four hours in rather considerable amounts, reliev- 
ing the kidney from the necessity of excreting nitrogen 
except that of endogenous origin. In these cases water ex- 
cretion is often low, not so much as a result of any imper- 
meability of the kidney to water as from conditions arising 
in any disease accompanied by fever, which is usually pres- 
ent in acute cases. The various methods to get water into 
and out of the system are advisable in certain cases, such as 
water by mouth, hot colon irrigations, hypodermoclysis, 
saline infusion (in very severe cases), hot packs and catharsis. 
All these methods both spare the kidneys and at the same time 
act favorably by flushing them out; just which methods 



NEPHRITIS 447 

shall be used must depend on. the severity of the case. If 
the less serious cases and on the second day in serious cases 
feedings may be begun; Tyson 1 recommends 2 ounces of 
milk every two hours for a few days. This is of course a 
modified form of the Karell diet which will be described 
under chronic nephritis. The quantity of milk can be in- 
creased as the urine secretion rises and to it may be added 
within several days farinaceous articles of diet, especially 
bread, cereals and barley gruel, all served with a moderate 
amount of sugar. Nothnagel recommends adding fats, as 
butter and cream, then light green vegetables; these latter 
according to most American usage are chosen chiefly from 
those varieties which grow above ground. 

Practically all authorities agree that a prolonged and exclu- 
sive milk diet is distinctly a bad thing, as it results in anor- 
exia, coated tongue and often in intestinal indigestion with 
diarrhea. There is no doubt, however, that milk should 
form the bulk of the diet in the acute cases, although it is 
well not to give a daily total of protein over 30 to 40 gm. at 
first, gradually increasing this perhaps to 70 to 80 gm., 
depending on excretion and the size of the patient. This 
lactofarinaceous vegetarian diet fills the requirements of food 
value, variety and bulk, with the minimum of renal irrita- 
tion. The appetite can usually be trusted to take approxi- 
mately sufficient food with the restrictions exercised parti- 
cularly in the protein foods as indicated, and although the 
total caloric value of the food will necessarily be low at first, 
it is better so, and as the appetite returns the quantity may 
be increased at will. Fischer's explanation of the benefit 
from a lactovegetarian diet is that it contains much fluid 
and that the salts in the vegetable fruits produce carbonates 
in the blood which in turn counteract renal acidosis. He 
also explains in the same manner the usefulness of the old 
empirical alkaline mixtures given for nephritis, such as the 
potash salts. 

If these cases are prolonged and become subacute, develop- 
ing edema and difficulty with salt and water excretion, they 
had best be put on one of the salt-poor diets, although accord- 
ing to Fischer even these cases need to have water in large 
amounts which if given by rectum and combined with sodium 
chloride and sodium carbonate, as already stated, reduce the 
general body acidity and results in the disappearance of the 
edema. As yet this plan has not met with general accept- 
ance, although there are some favorable reports. 

1 New York Med. Jour. January 31, 1914, p. 223. 



448 DISEA SES OF THE GEN I TO- URINA RY SYSTEM 

Most of the acute cases complicating or following infectious 
diseases fortunately clear up with care and gradually they 
may be returned to a normal diet, taking care for months 
that all irritants are excluded from the diet, such as much 
meat or meat soup, celery, garlic and onion, which on ac- 
count of irritating oils are injurious. Alcohol is best left 
absolutely alone and is not to be recommended for any pur- 
pose. If patients refuse to do entirely without alcohol, 
some of the light white or red wines when diluted with 
carbonated waters are preferable, but strong liquors, beers 
and ales should not be taken under any circumstances. 

Certain cases of acute nephritis, particularly those of idio- 
pathic or unknown origin tend to continue indefinitely and 
trail off into a subacute condition or one that becomes 
chronic. These, in their early stages are treated as are the 
other acute cases and when they may be said to have be- 
come chronic they follow the dietary rules of that class. 

Diet and Treatment for Acute Toxic Nephritis From Mer- 
cury Poisoning. — Mercury is not infrequently taken with sui- 
cidal intent or by mistake for headache tablets ; unless the poi- 
son is at once removed a severe form of toxic nephritis is set up 
if the dose is large, resulting eventually in complete anuria, 
coma and death unless relieved. The following treatment 
for these cases has been devised by Lambert and Patterson 1 
on the basis of laboratory experimentation of K. C. Vogel. 

The first indication is to give the patient the whites of 
several eggs as soon as it is known that mercury has been 
taken unless it is possible to perform lavage at once which 
should of course be done, leaving in a pint of milk after the 
lavage. Lavage should usually be performed as soon as the 
patient is seen. 

The following routine is instituted as soon as the patient 
ceases to vomit, the termination of which may be hastened 
by regular lavage. 

1. " Every other hour the patient is given 250 c.c (8 ounces 
of this mixture: Potassium bitartrate, 4 gm. (1 dram); 
sugar, 4 gm. (1 dram); lactose, 15 gm. (K oz.); lemon 
juice, 30 c.c (1 oz.); boiled water, 500 c.c. (16 oz.). Eight 
ounces of milk are given every alternate hour. " 

2. The drop method of rectal irrigation with a solution of 
potassium acetate, 4 gm. (1 dram) to the pint (500 c.c.) is 
given continuously. The amounts of urine secreted under 
this treatment are often very large. 

3. The stomach is washed out twice daily. 

4. The colon is irrigated twice daily in order to wash out 
whatever poison has been eliminated that way. 

5. The patient is given a daily sweat in a hot pack. 

^rch. Int. Med., November, 1915, p. 870. 



NEPHRITIS 449 

The colonic drip enteroclysis is kept up day and night with- 
out interruption. When one dose of mercury has been 
taken, the treatment may be stopped after two negative 
examinations of the urine for mercury. For the less severe 
cases treatment had best be kept up for one week. When 
large or repeated doses have been taken or where an old 
kidney disease is present the treatment should be kept up 
for three weeks, as the mercury is very slowly eliminated by 
the kidneys, stomach and bowel. 

Chronic Nephritis. — The diet in chronic nephritis in its 
various forms is a trying matter, for the cases are apt to run 
for years with occasional acute exacerbations, and great 
care is constantly required in order to prevent the recurrence 
of symptoms from injudicious diet and hygiene. In the 
acute cases of nephritis dieting is more stringent but of com- 
paratively short duration and the need for long-continued 
watchfulness is less imperative. The dietary treatment of 
the acute exacerbations, occurring in the course of chronic 
nephritis, is the same as in the acute cases and afterward 
the cases must be fed and managed with the idea in mind 
that they may live a fairly long life. 

Before turning directly to the subject of specific diets it 
seems worth while to give some attention in a short para- 
graph to the general management of chronic nephritis from 
a dietetic point of view. 

Dietetic Management of Chronic Nephritis. — i. As most 
cases of chronic nephritis have distinct limitations in regard 
to their excretory power of nitrogen, salts and water, it is 
absolutely necessary for their most intelligent dietary treat- 
ment that these limitations be determined, at least approxi- 
mately. 

2. Since in these cases diet is a matter of months or years, 
it is necessary to make sure that any diet chosen is palatable, 
supplies the full requirements in protein, fat, carbohydrate 
salts, and calories adjusted to the requirements of the 
particular case and avoiding undue increase in weight. 

3. In the long-standing cases it is not necessary to exclude 
meat absolutely except possibly in the cases with high 
arterial tension. Most authorities agree with Hare 1 in think- 
ing that the removal of red meat from the diet for a long 
period is harmful. Since it is the extractives which seem 
to contain the pressor substances, meat soups are much better 
excluded from the diet and boiled meat is more to be desired 
than meat broiled or roasted, as the boiling removes a large 

therapeutic Gazette, 1914, p. 615. 
29 



450 DISEA SES OF THE GENITO- URINA RY S YSTEM 

proportion of the extractives. Boiling in two waters is 
better still. 

4. The diet, so far as possible, must be kept laxative, as 
many cases of chronic nephritis are made distinctly worse 
when there is constipation. 

5. Von Noorden recommends once a week the giving of an 
extra one or two liters of water for the sake of its flushing 
effect. On these days the food is best limited to not over 
half the usual allowance. Of course when the patient is not 
excreting the ordinary daily allowance of water, it would be 
of doubtful utility to give this extra amount, although again 
Fischer insists that a kidney that is not secreting water in 
normal amount needs more water, provided it contains the 
necessary salts and alkali. 

6. The use of vegetables, fruits in large amount as already 
explained is of the greatest value in furnishing alkaline basic 
salts. 

Diets in Chronic Nephritis. — When in chronic nephritis 
there are no particular evidences of renal insufficiency, the 
diet should be distinctly of a prophylactic nature and should 
contain only the mild foods and unirritating substances. 
Such a diet may contain : 

Oysters, fresh fish, cream soups, vegetable purees made 
without meat stock. Eggs in limited number, not over one 
or two a day. Green vegetables, exclusive of those already 
mentioned as irritating to the kidneys. Fruits of all sorts. 
Meat, a little once a day (if there exists no contra-indication 
in hypertension) simply prepared. There is little difference 
between light meat or dark meat, mammalian meat, or that 
of fowl, except the latter probably contains a lower per- 
centage of extractives. Fats, butter and oil, mild cheese, 
farinaceous products such as cereals, breads, preferably stale, 
simple puddings and desserts. Milk, cream. Vichy, cider 
if sweet, grape juice or other unfermented fruit juices. Tea 
and coffee in moderation, avoiding other articles likely to 
disturb digestion. Alcohol has been disposed of under acute 
nephritis and what was said there applies equally to chronic 
nephritis and needs no discussion — it should not be used. 

Diet for Cases with Nitrogen Retention (Chronic Uremia.) 
— In these individuals there is the very distinct indication to 
feed small quantities of concentrated food with low total 
nitrogen content Miller 1 recommends for this purpose 
cream in a total daily amount of one pint, or one-quart half 
milk, half cream. This pint of cream furnishes 12.5 gm. 
protein, 92.5 gm. fat, 22.5 gm. carbohydrate and about 

1 Forchheimer's Therapeutics, vol. iv. 



NEPHRITIS 451 

iooo calories, or for the quart of half milk — half cream, pro- 
tein 29 gm., fat 112 gm., carbohydrate 47 gm., 1350 calories; 
to be sure an amount entirely inadequate to the general 
nutritional needs but sufficient for temporary use. These 
cases of chronic or acute uremia often do surprisingly well 
on this diet for a few days, extra water being allowed and 
given by mouth, hypodermoclysis, rectum or intravenously, 
with or without venesection. 

Nothnagel praises a milk diet in these uremic or "near 
uremic" conditions and recommends a liter of milk in twenty- 
four hours, then when better, increasing it to one and a half 
to two and a half liters per day. This is carried out for two 
weeks when the conditions are acute. At all other times an 
exclusive milk diet is unsuitable, but should constitute a 
considerable proportion of the daily ration plus vegetables, 
fruits and farinaceous foods. 

This condition of uremia with failure of nitrogen excretion 
Fischer ascribes to extreme renal acidosis and this condition 
of acidosis unquestionably exists as proven by estimations of 
C0 2 in the expired air. Acting on this theory cases are 
given alkalies by mouth, rectum or intravenously, often with 
marked benefit (?) in the diminution of the uremic symptoms. 

When the immediate danger of uremic coma or convul- 
sions is past one may increase the quantity of milk allowed, 
adding cereals at first, then vegetables, etc., gradually build- 
up the diet unless there are contra-indications on account of 
an existing edema with salt retention or water retention or 
both, when the limitations of diet for these conditions must 
be observed. 

In nephritis with nitrogen retention, but without difficulty 
in water elimination, Foster has shown it is often advan- 
tageous to push the water ingestion up to 3000 to 4000 c.c. 
(3 or 4 quarts), as in this way more nitrogen is swept out, 
for such patients cannot concentrate their urine and the only 
way of accomplishing elimination is by this method. One 
prerequisite, however, is a fairly competent circulatory 
apparatus. 

Diet in Water Retention. Edema. — This seldom occurs 
alone but is usually a part of a total picture of sodium chlor- 
ide and water retention together. It was formerly thought 
that the water retention was primary, but later the chloride 
retention assumed the leading role and the water retention 
went with it hand in hand in order to keep the chlorides at 
their normal concentration of a 0.6 to 0.9 per cent, solution. 
In these cases the salt-poor diets are often useful, or the 
Karell diet may be used to advantage. 



452 DISEASES OF THE GEN ITO-URI NARY SYSTEM 

The details of this latter are as follows: 

For first five to seven days: 200 c.c. (6>^ oz.) milk every 
four hours, at 8, 12, 4, and 8. No other fluids allowed. 

Eighth day: Milk as above and in addition, 
10 a.m. One soft-boiled egg. 
6 p.m. Two pieces of dry toast. 

Ninth day: Milk as above and in addition. 

10 A.M. One soft-boiled egg and two pieces dry 

toast. 
6 p.m. One soft-boiled egg and two pieces dry 
toast. 

Tenth day: Milk as above and in addition, 

12 noon Chopped meat (?), rice boiled in milk, 
vegetables. 
6 f.m. One soft-boiled egg. 

Eleventh and Twelfth days, same as tenth day. 

No salt is used at all throughout the diet. Salt-free toast 
and butter used. Small amounts of cracked ice are allowed 
with the diet. 

This method gives the kidney little water to excrete, and 
later it may resume secretion probably as a result of its rest. 
On the other hand, cases are sometimes seen in which the 
fluids have been limited to 800 to 1000 c.c. (27 to 33 oz.) 
but without therapeutic success, improve as soon as water is 
pushed, giving an extra 2000 c.c. or even more. 

Diet in Salt Retention. — Although this has been discussed 
slightly in connection with acute nephritis, it is in the chronic 
forms that we are apt to meet the long-standing and persis- 
tent cases with edema, due to chloride retention, accom- 
panied of course by water retention and where some form of 
diet poor in salt is indicated. Having determined the daily 
output of salt on a fixed salt diet, as well as the elimination 
time for some definite extra amount of salt, say 10 gm., we 
are in a position to know what form of salt-poor diet is 
indicated. Where no means exist for determining the chloride 
excretion it may be concluded with considerable confidence 
that when one finds edema complicating nephritis, in the 
presence of a fairly competent heart, it is due to primary 
chloride retention. 

If one finds sufficient indication for the use of milk from the 
character of the urine, e. g., much albumin, blood cells and 
casts, we can remember that the chloride content of one liter 
of milk is 1.6 gm., and if one uses the Karell diet of course in 
the 800 c.c. there would be only 1.2 gm., of salt for the first 
few days of milk. When it is not necessary to use solely a 
milk diet even for a few days one can make use to advantage 



NEPHRITIS 



453 



of one of the salt-poor diets, beginning with No. I, then No. 
2 or No. 3, gradually working toward a modified normal 
dietary exclusive of the renal irritants. 

In using the salt-poor diets it is necessary to keep in mind 
the fact that many cases in whom the edema is due unques- 
tionably to chloride retention do not begin to clear up on the 
salt-poor diet as rapidly as one could wish or might, expect, 
but that in many instances the diet has to be continued for a 
week or longer before the rapid emptying of the tissues of 
salt and water takes place. Still other cases are even more 
resistant. 

The explanation of this fact is not always clear but it seems 
likely that sparing the kidney for some time finally results in 
a restoration of its power to excrete salt. 

While these salt-poor diets are primarily designed for use 
in the diet of nephritis, other conditions accompanied by 
edema, such as chronic cardiac diseases, are often greatly 
benefited, and in fact collections of fluid in the serous cavi- 
ties are frequently favorably influenced by one or another of 
these forms of salt-poor diet. 

In this diet, the cereals — butter, bread, etc. — used are all prepared without salt. 
Salt-poor Diet No. i. 

Breakfast. Gra. Oz. 

Farina 6o 2 

Bread 30 1 

Butter (unsalted) 30 1 

Sugar 10 y z 

Egg (1) 40 iH 

Coffee 175 5^ 

Prunes, stewed 60 2 



405 



133^ 



Dinner. 



Rice .... 

Farina . 

Bread . . . 

Butter (unsalted) 

Sugar 

Tea .... 



Gm. 
60 

IOO 
30 
20 
IO 

175 



Oz. 



Vz 

5 2 A 



Toast 

Egg (1) . . 
Bread . . . 
Butter (unsalted) 
Sugar . 
Custard 
Baked apple 
Tea .... 



Supper. 
Gm. 

15 
40 
30 
15 
10 

IOO 
60 

175 



Oz. 

I 

Vz 
% 

2>Vz 



395 13 

Approximate Values. 



445 



HVs 



Protein 36 gm. {1% oz.); fat 65 gm. (2% oz.); carbohydrate 160 gm. (53^ oz.): 
calories 1350; chlorids 1. gm. 



454 DISEASES OF THE GEN ITO-URI NARY SYSTEM 



Salt-poor Diet No. 2. 



Breakfast. 



Dinner. 





Gm. 


Oz. 


Egg (1) . . . 


40 


iH 


Farina . 


60 


2 


Bread . . . 


65 


2% 


Butter (unsalted) 


30 


1 


Coffee 


175 


5Vz 


Prunes or baked 






apple . 


60 


2 



Egg (1) . . 

Bread 

Butter (unsalted) 

Farina . 

Sugar 

Rice 

Tea .... 



430 



14 



Gm. 
40 
60 

35 

100 

10 

60 

175 

480 



Supper. 



Toast .... 
Egg (1) . . . 
Butter (unsalted) 
Bread .... 
Custard . 
Baked apple . 
Prunes . . .. 
Tea .... 



Gm. 

15 
40 
30 
60 
IOO 

60 

60 

175 



Oz. 
2 

iVz 
Vz 

hi 

Oz. 

l A 
1 

iVz 

2 
iVz 



540 173^2 

Approximate Values. 
Protein 51 gm. (1% oz.); fat 100 gm. (3^ oz.); carbohydrate 250 gm. (83^ oz.); 
calories 2150; chlorids 1.4 gm. 



Breakfast. 



Salt-poor Diet No. 3. 



Luncheon. 



Gm. 


Oz. 


Bread .... 30 


1 


Egg (i) . . . . 40 


iH 


Wheat or corn cereal 60 


2 


Orange juice . . 200 c.c. 


6% 


Sugar .... 25 


b A 


Butter .... 20 


Vz 


Cream .... 50 


iVz 



younj 



Potato or 

carrots 
Bread . 
Rice 
Tomato 
Butter . 
Raisins . 
Sugar . 
Ice cream 

Supper. Gm. 

Bread 40 

Butter 30 

Wheat or corn cereal 60 

Cream 50 

Raisins 10 

Sugar 35 

Potato or young carrots 50 

Egg (1) 

Approximate Values. 
Protein 37 gm. {i x /§ oz.) (5.9 gm. nitrogen); calories 2000; 
1 gm. (15 grains). 

Salt-poor Diet No. 4. 



Gm. 

50 
30 
80 
IOO 
20 

15 

IO 

IOO 



Oz. 

iVz 
Ws 

zVz 

Vz 

¥?, 

Vz 

2>Vz 



Oz. 

1 

2 
iVz 

Vz 



:hlorides about 



Breakfast 






Luncheon. 






Gm. 


Oz. 




Gm. 


Oz 


Bread . . . 


60 


2 


Bread . . . 


40 


iVx 


Orange juice 


200 C.C. 


6Vz 


Butter . . . 


20 


Vz 


Butter . . . 


40 


iVz 


Egg (1) . . 


40 


iH 


Cream . 


30 


1 


Potato or carrots 


125 


4 


Farina . 


50 


iVz 


Cream cheese . 


20 


Vz 


Sugar 


30 




Sugar 


30 


1 


Coffee or tea 


180 C.C. 


6 


Rice . . . 


50 


1% 








Cream . 


30 


1 



NEPHRITIS 



455 



i 



Supper. Gm. Oz. 

Bread 50 i%3 

Butter 35 

Farina 50 

Cream 40 

Cream cheese .......... 30 

Olive oil 15 

Lactose 8 \i 

Sugar 30 1 

Potato or carrots 75 2 x /i 

May have in addition moderate amount of tomatoes, lettuce, cabbage, cauli- 
flower, spinach (fresh), beets, carrots, squash, oranges, grape-fruit, peaches, 
grapes, apricots, pears, melons, jams. 

Approximate Values. 



Protein 35 gm. (] 


% oz.; 


(5.6 gm. nitre 


gen); calories 2600; 


chlorides 


about 


1 gm. (15 grains). 




Salt-poor 


Di 


et No. 5. 






Breakfast. 








Luncheon. 








(Higher protei 


1.) 










Gm. 


Oz. 






Gm. 


Oz. 


Bread .... 


60 


2 




Bread . . . 


40 


iV* 


Orange juice 


200 


6Vb 




Butter . . . 


IO 


H 


Butter .... 


30 


1 




Potato or carrots 


80 


2 l A 


Eggs (2) 


80 


2^ 




Meat — choice of: 






Wheat or corn cereal 


90 


3 




Lamb chop or 


100 


tH 


Fresh fruit . 


50 


l% 




Steak or . 


100 


3^ 


Cream .... 


40 


iVs 




Chicken . 


• 125 


4 


Sugar .... 


50 


1% 




Fish . . . 


70 


2H 


Tea or coffee 


150 c.c 




Rice 


80 


2% 










Cream . 


20 


% 










Vegetables from list. 





Supper. Gm. 

Bread 50 

Butter 30 

Cream 40 

Lactose 8 

Cereal 30 

Stewed fruit 100 

Olive oil 20 

Eggs (2) 80 

Sugar 30 

Tea .150 

The same list of accessory fruits and vegetables that was given wi 
No. 4 is available here. 



Oz. 



3 l A 
% 
2^ 
1 
5 
th Diet 



Approximate Values. 
Protein 69 gm. (2^ oz.); nitrogen 11 gm. {% oz.); chlorides 
grains) ; calories 3000. 

Table of Salt Content of Common Foods. 

Per cent. 

Milk. . . 0.18 

Beef broth 0.735 

1 egg 0.086 

Chicken broth . 0.35 

Pea soup 0-499 

Ordinary white bread (not salt-free) .... 0.701 

Rice 0.748 

Boiled potato 0.058 



■1-5 05-23 



456 DISEASES OF THE GENITO-URINARY SYSTEM 

Chicken O.OI 

Beef .0.04 

Lamb chops 0-97 (Coleman) 

Pickerel . . . o.iO] 

Cod 0.59' 

Salmon 0.46 i Schall-Heisler 

Haddock 0.59! 

Oatmeal gruel 0075 

Macaroni . . . 0.07 

Beans . 0.0058 

Carrots 0.029 

Applesauce 0.0025 

Conclusion. — Thus it will be seen that if care is taken in 
determining the type of nephritis, whether acute or chronic, 
and as well, which of the functions are principally disturbed, 
much can be done by dietary regulation to spare a diseased 
kidney unnecessary labor, and at the same time furnish the 
organism with the food distinctly appropriate to the needs 
of each individual case. 

PYELITIS. 

Whatever the cause of the irritation in the pelvis of the 
kidney may be, whether from calculus or infection, the 
dietetic indications are plain enough. As soon as the trouble 
is recognized the patient should be put on a milk diet with a 
certain allowance of farinaceous gruel and large amounts of 
water urged, either as plain water or mild, alkaline drinks, 
such as Vichy or Vichy and water, equal parts, or water with 
1 gm. (15 grains) of bicarbonate of soda added to each 
glassful. (If urotropin is used to combat the infection, noth- 
ing should be used to reduce the natural acidity of the urine, 
as this drug is only decomposed in an acid medium.) As 
soon as the fever is over one may give a lactofarinaceous diet 
with green vegetables and later return to a mixed diet, but 
with the meat strictly limited to a very small portion, not 
more than once a day. No condiments of any kind should 
be allowed and alcohol in every form is contra-indicated. 

If nephritis occurs as a complication of the infection the 
diet should be regulated in much the same way except that 
the return to mixed feeding should be delayed until all signs 
of the acute process in the kidney substance have subsided. 
Attention must be given to preventing constipation, and for 
this purpose some of the mild saline laxative waters may be 
used or aloes and podophylin, cascara, etc. If edema de- 
velops as a consequence of nephritis it will be necessary to 
make use of one or other of the salt-poor diets, as detailed 
under nephritis. 

One important fact to remember is, that a continued flush- 
ing of the kidney pelvis by large quantities of ingested fluid 



NEPHROLITHIASIS 457 

removes the products of irritation and helps greatly in the 
healing process. 

CYSTITIS. 

Practically the same dietetic rules given for pyelitis hold 
good in cystitis for the difference in the location of the infec- 
tion does not cause any change in the dietetic requirements. 
A bland diet at first, largely fluid, and always containing 
considerable amounts of liquid, is the factor of chief import- 
ance; the same abstinence in the use of alcohol and condi- 
ments or irritants is observed as in pyelitis. 

GONORRHEA. 

Even with a specific infection of the anterior and posterior 
urethra and possibly the complicating cystitis and prosta- 
titis the diet conforms very largely to that already recom- 
mended for pyelitis and cystitis. In the early stages a milk 
diet for a few days, to reduce the irritation, combined with 
alkaline drinks, to change the reaction of the urine to alka- 
line, will make the patients much more comfortable. The 
diet may then be enlarged by the use of all farinaceous and 
vegetable foods, eggs, milk products, cheese, etc., and, when 
the inflammatory process reaches the subacute stage, the 
addition of meat once a day is entirely allowable. 

Foods to be particularly avoided are: all forms of spiced 
and highly seasoned food and condiments, alcohol in any 
form whatever, strong tea and coffee, acid fruits, tomatoes 
and asparagus. 

It should be remembered that a discharge that is almost 
cured may be readily started again by an indulgence in irri- 
tating foods or drink. This is especially true of the use of 
alcohol. If it should seem necessary for any reason to take 
some form of alcoholic drink, a diluted light claret or white 
wine is best, using an alkaline water, such as Vichy or Apolli- 
naris as a diluent. However, too much stress cannot be 
laid upon the avoidance of any alcohol. 

NEPHROLITHIASIS. 

The majority of calculi belong to one of three classes, uric 
acid, phosphates or oxalates. Uric acid and oxalate calculi 
are found in acid urine, phosphatic calculi in alkaline urine 
and these latter are more apt to come secondary to infection 
and fermentation. 

The diet must be simple, avoiding all rich foods and sauces 
or a great variety at one meal and should be sufficient for the 
needs of the body but with no surplus. 



458 DISEA SES OF THE GENITO- URINA RY SYSTEM 

If the stone is of uric acid, a purine-free or low purine diet 
should be insisted upon, omitting meats, particularly gland- 
ular organs, soups and all highly seasoned foods. Sugar 
and fat may be taken moderately. Hindhede has shown 
that vegetable eaters urine has an increased ability to dis- 
solve uric acid so that presumably a low purine and high 
vegetable diet does most in preventing uric acid stone 
formation. 

When the stone is of the oxalate variety all the foods that 
contain oxalic acid in excess should be left out of the diet, 
notably strawberries, rhubarb, figs, apples, peas and spinach. 
Most of the other vegetables except beans and peas are also 
theoretically best left alone, as they all contain an excess of 
lime, rendering the oxalate more insoluble. As a matter of 
fact however, the fruits and vegetables containing an excess 
of oxalic acid are the ones to be curtailed. 

Meat, in all except glandular form, is allowed freely. This 
same general dietary rule holds for phosphatic calculi. 

In all but phosphatic stones the use of alkaline mineral 
waters is allowed and does good not by virtue of dissolving 
the stone, but by flushing the kidneys, rendering the urine 
less acid with the consequent lessened chance of further cal- 
careous deposit. 

It is best to keep the urine faintly acid or neutral but not 
alkaline, in the latter instance it favors the deposit of phos- 
phates either a calculi or as a coating to a uric acid calculus. 

Water in large amounts is recommended to dilute the urine 
and flush the kidneys, so preventing much of the further 
deposition of salts. 

AMYLOID KIDNEY. 

There are no special indications for diet in this condition 
so far as the amyloid disease itself is concerned, but since in 
this condition the excretory power of the tubules is dimin- 
ished the nitrogenous foods should be kept at rather a low 
point, 40 to 60 gm. (ij^j to 2 oz.), per day while the total 
food value of the diet should be high to help combat the 
chronic infection almost always present somewhere in the 
body, which is the active cause of the amyloid degeneration. 



CHAPTER XXVI. 

DISEASES OR PATHOLOGICAL STATES DUE TO 
DISTURBANCES OF NORMAL METABOLISM. 

Of course in all diseases there are disturbances of metabo- 
lism, so in setting apart a classification such as this we mean 
merely that in the following diseases the abnormal anabolism 
or catabolism assumes the chief role, notwithstanding every- 
thing else. On this account it is not always easy to say just 
which diseases shall be included in this class, and as in the 
other classifications it is more than probable that a certain 
amount of rearrangement will be necessary as time passes. 

In all these states the resultant conditions are more com- 
parable to the results of hyperfunction or hypofunction of 
certain sets of glands which control growth and body ex- 
change, rather than to actual disease, although the line is 
often not sharply drawn between the two, for that which 
starts merely as a functional disturbance may progress to 
the proportions of a fatal disease, e. g., alimentary glycos- 
uria and severe diabetes. 

DIABETES INSIPIDUS. 

This disease, characterized by the passage of large amounts 
of urine of low specific gravity, is probably due to a functional 
or organic disease of the brain and there is also a possibility 
that the center in the medulla which controls the renal blood 
supply as well as excretion, is affected. 1 

Disease in or about the hypophysis is often associated with 
diabetes insipidus and Frank 2 has suggested the theory that 
excessive function of this gland is the cause of the disease. 
The injection of pituitrin often helps these cases, which would 
rather make it seem as if a hypofunction of the gland were 
more probable than excessive secretion. 

11 Minkowski 3 advises that the amount of chlorides and 
specific gravity of the urine be determined after the ingestion 
of considerable salt. If both increase relatively more than 
the urine does, he believes that the power of excreting a 
concentrated urine is still possessed by the kidneys. There- 
fore diminishing the amount of water drunk by the patients 

a Ref. Handbook Med. Sc, 3d ed., p. 516. 
2 Berl. klin. Wchnschr., xlix, 9. 
3 Therapeutic die Gag., 1910, p. 1. 

459 



460 DISTURBANCES OF NORMAL METABOLISM 

will help them. If the amount of urine increases relatively 
the more, a salt-free diet and one poor in protein will be a 
help." 

In choosing a diet it is necessary to avoid foods that cause 
indigestion or flatulence, particular restriction being placed 
on sugar, for when an excess of this is taken it tends to raise 
the percentage of sugar in the blood, which aggravates the 
polyuria. Cold drinks which are diuretic must be given up, 
as cold milk, beer, cider, also watery fruits. A salt-poor and 
low protein diet tend to diminish the quantity of urine when 
the kidneys do not concentrate the urine normally. 

DIABETES MELLITUS. 

In perhaps no other disease is diet such a matter of vital 
importance as in diabetes mellitus, for as time has gone on 
and one after another procedure or drug has been vaunted as 
a cure only to be cast aside as entirely wanting, diet has 
remained as the one factor which is capable, if properly 
employed, of resting the glycogenic function of the liver, and 
in all but the most severe and necessarily fatal cases is also 
capable of bringing about a condition more or less approach- 
ing the normal. By its proper employment the mild cases 
are clinically cured, the moderately severe are rendered mild 
and the most of the very severe are changed to cases of 
moderate severity. 

An extended discussion of the pathological physiology and 
disturbed metabolism of diabetes is not necessarily a part of 
a book on dietetics but it is necessary to discuss the import- 
ant changes of metabolism if one is to appreciate, to even a 
small degree, the importance and significance of diet in the 
varying phases of this disease. 

Interest naturally centers about carbohydrate metabol- 
ism which formerly was thought to be the only matter of 
importance and that the metabolism of protein and fat in no 
way entered into the question for the diabetic. Following 
this, the importance of fats in the production of acidosis was 
discovered, and last of all the fact that the body could syn- 
thesize sugar out of protein. With this last the whole ques- 
tion of diet in diabetes was revolutionized at a stroke and an 
explanation was at hand as to why certain cases failed to 
become sugar-free on a meat-fat diet. Another significant 
change of thought has been that formerly attention was 
focussed on the glycosuria as the most important index of a 
disturbed sugar metabolism, whereas now the hypergly- 
cemia, which always accompanies glycosuria, except in the 
few cases of so-called renal diabetes, occupies chief attention, 



DIABETES MELLITUS 461 

since it is found that many cases of diabetes get rid of their 
glycosuria and would formerly have been pronounced cured 
but are found to retain their hyperglycemia, thus still show- 
ing evidence of a disturbed sugar metabolism. 

When we come to study the various aspects of the sugar 
question we do not find unanimity of opinion. Claude Ber- 
nard, Lowe and von Noorden believing that diabetes is due 
to disturbance of sugar production, while Naunyn and Min- 
kowski believe it due to a disturbance of sugar burning. 1 
Hepatic disorders or pathological states were blamed in time 
past while now the liver is believed by most to be little more 
than the organ which stores sugar or glycogen and is ' ' played 
upon" so to speak, by other organs by which the process of 
sugar excretion by the liver is stimulated or depressed. If 
we will refresh our memories by reference to normal physi- 
ology and then its application to diseased states, we will get 
a better idea of the question which is so well put by von 
Noorden. 2 

The liver is the organ which renders sugar available for an 
immediate source of energy and maintains the sugar content 
of the blood at 0.075 to 0.1 per cent. If the liver produces 
more sugar than is required by the tissues, there is an in- 
creased amount of it in the blood (hyperglycemia) under which 
condition some escapes in the urine. If, on the other hand, 
the liver does not supply enough sugar to the blood, the 
muscles are the first to surfer and the individual feels fatigue, 
as occurs after severe labor. 

In a condition of alimentary glycosuria the amount of 
sugar ingested is excessive and cannot be used up, so is ex- 
creted in the urine. In order to prevent this, however, the 
liver stores the sugar as insoluble glycogen which forms a 
reserve supply. By the action of glycogenase, also found in 
large amounts in the liver and more or less universally in the 
body, the glycogen is reconverted into soluble sugar again 
and so goes into the blood. If for any reason the ordinary 
supply of carbohydrate is withheld the liver can form sugar 
out of the protein and fat. 

In health the supply and demand for sugar in the blood 
are exactly balanced and regulated, i. e., the liver does not 
split up more glycogen for the use of the body than neces- 
sary. There are at least two factors which according to von 
Noorden influence the function of sugar making, viz., the 
pancreas and the suprarenals, the foimer a depressant, the 
latter excitants to sugar formation. According to this 

1 Berl. klin Wchnschr., 1913, p. 2161. 
2 Am. Jour. Med. Sc, 1913, cxlv, 1. 



462 DISTURBANCES OF NORMAL METABOLISM 

theory, from the pancreas there goes to the liver a specific 
secretion (an internal secretion, presumably from the islands 
of Langerhans) which acts as a depressant to sugar formation 
in the liver. If the pancreas is removed, so is this break in 
sugar production, and the diastase acting unhindered causes 
an excessive sugar output from the liver, which is excreted 
in the urine. This, von Noorden says, is really a severe 
diabetes. 

Adrenalin excites the production of sugar by the liver and 
a small amount of it is constantly being excreted by the 
suprarenals and absorbed by the blood. Therefore the 
suprarenals antagonize the action of the pancreas in its 
relation to sugar production and these two glandular sys- 
tems really control the sugar production by the diastase in 
the liver. The suprarenals do not act alone, for "they are 
especially under the control of the nervous system." The 
Claude Bernard center in the medulla is the point from which 
go out impulses that stimulate the suprarenals to hyperfunc- 
tion through the sympathetic nerves and thereby cause 
glycosuria. The pancreas is not independent either, for it 
is under the control of the thyroid and when the thyroid 
overfunctionates the pancreatic function is paralyzed and 
the glycogenase in the liver again acts unhindered, resulting 
in the overproduction of sugar and glycosuria. So in Grave's 
disease we see glycosuria and in myxedema increased sugar 
tolerance. The pancreas is also probably affected by other 
factors as yet unknown. 

This theory is visualized by the diagram on page 463. 
The arrows represent the direction of the stimuli and the 
plus or minus signs whether the stimulus is an excitant or 
depressant on the next orp-an. 

Besides the disturbance in carbohydrate metabolism we 
have to consider carefully that of protein and fat. 

The Relation of Protein Metabolism to Glycosuria.— 
Protein metabolism in the mild forms of diabetes probably 
proceeds normally and requires no further discussion, but in 
the more severe varieties we have other factors that must be 
taken into consideration. In 1913, Cammidge 1 called at- 
tention to the fact that in estimating the degree of toxicosis 
in diabetes, one should take into consideration the complete 
picture and that three stages should be distinguished. In 
two of the three "the defect in metabolism is confined to a 
more or less complete inability to make use of the sugar 
derived from the carbohydrate foods, but amino-acids are 
still available as a source of energy and the body makes use 

lancet, 1913, ii, 1319. 



DIABETES MELLITUS 



463 



of these supplemented in the milder forms by a certain 
amount of sugar derived from starchy foods and fats, for its 
needs. In the third form, to which the name 'diabetes' is 
confined by some writers, the power to metabolize amino- 
acids is diminished, with the result that these bodies appear 
in the urine and gradually increase in amount as the meta- 
bolic defect becomes more pronounced. Even in the most 
serious cases, however, some of the amino-acids are diami- 
nized and converted into dextrose, thus contributing to the 
sugar excreted in the urine, while the fatty acids of others 
are imperfectly oxidized and give rise to the 'acetone bodies' 
(acetone, aceto-acetic acid and 0-hydroxybutyric acid) that 
are passed at the same tmie. Estimations of the amino- 
acids, 'acetone bodies' and sugar give therefore a much more 
complete picture of the state of the metabolism than any one 
of these taken alone, and by considering them in conjunction 
with the effects produced by a diet of which the qualitative 
and quantitative composition is known, we can determine 
the stage that has been reached and the probable expecta- 
tion of life." 




Panoreat 



Adrenals etc. 



These findings go with the clinical observation that when 
the diabetes is severe, the protein should be curtailed and 
intervals of a meat-free diet given. 

Animal food is rich in those forms of protein which the 
disturbed organism finds it difficult to break down and util- 
ize, while vegetable proteins are poor in these constituents 
and a larger proportion of amino-acids which can be made 
use of to supply the energy needed by the tissues. Egg pro- 
tein is more like vegetable protein in this respect and can be 



464 DISTURB A NCES OF NORMA L ME TA BOLISM 

used safely where other animal protein is forbidden. Milk 
however, is like the meat protein. 

When we find a patient with amino-acids in the urine we 
must determine whether they are from the food or from 
breaking down of their own tissues and if from the food 
whether they can still take care of the protein from egg and 
vegetable. If omitting animal proteins results in freeing 
the urine of amino-acids, as is the case in gout, the progno- 
sis is better and the outlook with proper diet of getting rid of 
glycosuria is good, but if we are not able, by regulating the 
diet, to get rid of the amino-acids the outlook is poor. This 
constitutes the third or true diabetic stage. 

The Nitrogen Balance in Diabetes. — Cammidge 1 in calcu- 
lating the intake and output of nitrogen in a severe case of 
diabetes found that with an intake of 12 gm. nitrogen and 
52 gm. carbohydrate, the urine showed 31.8 gm. nitrogen 
with high acetone bodies, ammonia nitrogen, calcium and 
magnesium and 229 gm. sugar. This demonstrated that 
the patient was forming sugar from his own tissues. This 
together with the abnormal excretion of amino-acids, uric 
acid and creatinin showed that there was a high degree of 
tissue waste accompanied by defective protein metabolism. 
When in this case the nitrogen intake was reduced to 3 gm. 
still keeping the sugar value of the diet at nearly the same 
level, resulted in the fall of sugar excretion to less than one- 
half its former amount, the blood sugar fell from 0.3 to 0.2 
per cent, and the alveolar carbon dioxide rose to 4.6 per cent, 
from 0.75 per cent, before; the /3-oxybutyric acid also fell 
from 19.7 to 3.6 gm. accompanied by a clinical improvement. 
Sufficient has been said to leave no doubt in the mind that 
the sugar excretion is markedly influenced by protein metab- 
olism and that it is not possible in severe diabetes to make 
up a deficiency of carbohydrate in the diet by feeding large 
amounts of protein. Until this fact was learned it was not 
understood why a diabetic continued to excrete sugar on a 
carbohydrate-free diet and that it was not until the protein 
was reduced or changed from a meat to an egg protein that 
the patient began to be sugar-free. 

In this connection reference should be made to coma occur- 
ring in some cases of severe diabetes due to a perverted pro- 
tein metabolism not associated with a ketonuria. Kraus, 3 
Rumpf 3 and Lepine 4 and others showed that cases of dia- 
betic coma occurred without any increase of organic acids in 

lancet, 1915, ii, 1187. 

2 Zeit. f. Heilk,. 1906, x, 1899. 

3 Berl. klin. Wchnschr., 1895, xxxii, 185, 669, 700. 

4 Rev. d. med., 1887, xii, 224; 1888, xiii, 1004. 



DIABETES MELLITUS 465 

the urine and Rosenbloom 1 reports 3 cases of typical coma 
occurring in severe diabetes with no carbohydrate tolerance, 
and even with a restricted protein intake the glycosuria was 
not diminished. They were observed weeks or months dur- 
ing all of which time the urine contained an average normal 
amount of ammonia nitrogen, no ketone bodies nor was there 
any evidence of kidney disease. All 3 cases died in typical 
diabetic coma. Here we have an effect from abnormal pro- 
tein metabolism which must be taken into account when 
dealing with severe diabetes, and its clinical application to 
dietetics is plain. 

Relation of Fat Metabolism to Glycosuria. — As is well 
known the normal end-products of fat metabolism are water 
and C0 2 ; the body fats are chiefly palmitic, stearic, and 
oleic acids, all of which contain an even number of carbons 
in their respective molecules. Although protein can add to 
the formation of acetone bodies, they arise mainly from fat. 
The complete breaking down of the fatty acids is not alto- 
gether an independent process, as it is largely dependent on 
the presence of carbohydrate in the diet as well as upon the 
ability of the organism, to metabolize carbohydrates. 2 

Fat does not act as a stimulant to sugar production as does 
protein but is a source of sugar, although it is only used by 
the liver in making glycogen when other supplies fail. In 
severe diabetes, however, the body fat is used in large amount 
so resulting in emaciation. 3 

In severe diabetics with no carbohydrate tolerance the 
butyric acid molecule formed in intermediary metabolism 
of the fatty acids becomes incompletely oxidized only to 
0-oxybutyric, aceto-acetic acids, and acetone which last is 
derived from the two former acids. Ringer believes that 
"one of the functions of the glucose molecule in normal 
metabolism is to make /3-oxybutyric acid, which arises con- 
stantly in the catabolism of the higher fatty acids, combus- 
tible," and he concludes that if we could find fats with an 
uneven number of carbon atoms they would be oxidized 
into glucose instead of acetone bodies. In these conditions 
of perverted fat metabolism and ketonuria, although we 
speak of acidosis, by this is meant the accumulation of acid 
bodies in the blood and tissues sufficient to neutralize enough 
of the sodium bicarbonate there present to reduce the alkal- 
ine reserve to a level below normal; it does not mean that 
blood and tissues become actually acid in reaction. 4 

x New York Med. Jour., August 7, 1915. 

2 Ringer: Tr. Assn. Am. Phys., 1913, xxviii, 469. 



3 Von Noorden: Am. Jour. Med. Sc, 1913, cxlv, 1. 
4 Stillman: Med. Rec, 19 16, Ixxxix, 390. 



30 



466 DISTURB A NCES OF NORMA L ME TA BOLISM 

Although ketonuria is more apt to be extreme when there 
is no carbohydrate tolerance, it is a fact that considerable 
amounts of acid bodies may be excreted when the carbohy- 
drate tolerance is 20 to 30 gm. In long fasting, man shows 
a fall in his respiratory quotient while the diabetic shows 
some tendency to a rise. Such observation leads to the 
belief that the diabetic even in the severest cases burns some 
sugar or some other body substance to compensate for it. 
Joslin 1 says there is much experimental evidence that the 
other body substances are the acids. 0-oxybutryric acid 
has a high caloric value and yields a high respiratory quo- 
tient. 

Hyperglycemia. — Before proceeding to the discussion of 
diets in diabetes a word about hyperglycemia is in place, the 
various causes of which as given by Dock 2 are as follows : 

1. Excessive ingestion of sugar. 

2. Reduction of liver function. 

3. Exaggeration of the glycolytic function of the liver. 

4. Reduction of the glycolytic function of the muscles. 

5. Exaggeration of the glycolytic function of the muscles. 

6. Reduction of formation of fat from glucose. 

7. Reduction of combustion of glucose in the muscles. 
Since in diabetes mellitus one or more of these functions 

may be disturbed we see what a various etiology of hyper- 
glycemia there may be, and it is a much more accurate index 
of perverted metabolism in diabetes than is glycosuria. 

While an increase of blood sugar over the normal (0.07 to 
0.14) percent, is usually unfavorable in diabetes, Mosenthal a 
says that diabetic patients by raising the fasting or basal blood 
sugar percentage, tend to adjust their carbohydrate meta- 
bolism in such a manner that they are able to utilize the food 
offered them to better advantage. While a low blood sugar 
is usually considered best it may not be desirable in all cases 
of diabetes mellitus to reduce this. 

According to Williams and Humphrey 4 the renal threshold 
for blood sugar tends to rise with the age of the patient, — 
younger diabetics have a low or normal threshold and when 
the diabetes is mild or quiescent the point at which the kid- 
neys eliminate sugar is stationary, but when the disease 
becomes progressive the threshold tends to rise. Before 
death the blood sugar renal threshold may reach great 
heights with little or no sugar in the urine. 

1 New York Med. Jour., 1915, ci, 628. 

2 Int. Cong. Med., 6 Med., p. 234. 

3 Johns Hopkins Hosp. Med. Bull., 1918, xxix, 94. 

4 Arch. Int. Med., xxiii, 537. 



DIABETES MELLITUS 467 

Dietetic Treatment of Diabetes. — The dietetic treatment 
of diabetes mellitus resolves itself into the questions as to 
how much carbohydrate the individual can utilize and how a 
tolerance for carbohydrate can be obtained or increased. 

If, as Allen says, we compare the glycosuria to a gastro- 
intestinal indigestion, due to either a functional or organic 
disturbance, we see at once that what is needed is rest for the 
deranged function, followed by a gradual system of dietetic 
reeducation, principally so far as the carbohydrates are con- 
cerned, until step by step the body can take care of slowly 
increased amounts of this food element. 

The avoidance of overstrain of the glycogenic function 
must be kept ever in mind, for if during the process of reedu- 
cation sufficient food is given to again precipitate the gly- 
cosuria this puts off the further advance disproportionately 
and if it is continued, quickly results in the loss of the bettered 
function obtained by previous careful dieting. In other 
words "over-strain weakens while rest strengthens any 
damaged function. 1 

Mosenthal 2 studying the maintenance diet in diabetes 
found the standard in one of two criteria. 

I: The caloric requirement as determined by the height- 
weight formula of DuBois & DuBois 3 . 

2. The nitrogenous equilibrium as the lowest possible 
food standard of maintaining physical and mental well-being. 

On this basis the loss of weight found favorable nowadays 
in diabetes comes from fat and not from vital protein. He 
further investigated the food value of protein, fat and alco- 
hol in nitrogenous equilibrium of diabetes and concluded 
that "the addition of an equal number of calories of protein, 
fat or alcohol to a low caloric carbohydrate-free diet in cases 
of diabetes results in the assimilation of considerable amounts 
of nitrogen when protein is used, a favorable N balance in 
only occasional instances with fat and no change in N equili- 
brium when alcohol is given. This would point to a high 
protein diet as the most desirable low caloric carbohydrate- 
free diet by which to conserve the body tissues and furnish 
a maintenance diet for the diabetic." 

On the basis of what is known in regard to the relation of 
amino-acids to sugar production the high protein diet ad- 
vised by Mosenthal would better be of the protein with 
little or no purine (see Purine Content of Various Foods). 

1 Foster: Diabetes Mellitus, p. 183. 

2 Arch. Int. Med., 1918, xxi, 269. 

3 Ibid., 1916. xvii, 863. 



468 DISTURB A NCES OF NORMAL METABOLISM 

In considering the details of dietetic management we have 
two principal methods of treatment, one the European, best 
exemplified perhaps by the von Noorden routine, and the 
other an American method, known as Allen's fasting cure for 
diabetes. While there are of course numerous modifications 
of these methods and to a certain extent they are modifica- 
tions of each other, the von Noorden cure puts the emphasis 
on first finding the carbohydrate tolerance, if any, by begin- 
ning with increasing or diminishing amounts of carbohy- 
drate with a certain amount of modified starvation in severe 
cases, for a day or two. Allen's method lays stress on the 
fasting phase of the treatment, the reduction of weight of 
the patient and keeping the total caloric value of the food 
low when feedings are begun. The fats are kept particu- 
larly low, for if given in any considerable quantities the car- 
bohydrate tolerance is reduced. The fast is persisted in 
until the urine becomes sugar-free and the ketone bodies 
usually drop, but do not as a rule disappear until the patients 
are fed after their fast. When the patient is sugar-free, 
carbohydrate is allowed in small amount and gradually in- 
creased to tolerance, quite as much emphasis being also put 
on the protein and fat tolerance in their relation to hyper- 
glycemia. 

Von Noorden Method. — For a differentiation of the treat- 
ment we may arbitrarily divide diabetics into three classes 
of cases. 

i. Those in whom the sugar excretion is less than 50 gm. 
without ketonuria. 

2. Those in whom the sugar excretion is more than 50 gm. 
also without ketonuria. 

3. Those in whom the sugar excretion is more than 50 gm. 
with ketonuria. 1 

The first step is the determination of the individual's 
carbohydrate tolerance if such be present. In the very mild 
cases associated with overeating of sweets and starches it is 
usually only necessary to order a rational diet curtailing these 
food elements to promptly and permanently render these 
people sugar-free. On the other hand any glycosuria even 
a so-called alimentary form due to excessive ingestion of 
sugar-forming foods must be viewed as a real diabetes, al- 
though mild, and with potency for developing into a severe 
grade if neglected. (Even these mild cases should be taught 
to examine their own urine with Benedict's solution once in 
so often in order to be sure that the sugar does not recur.) 

1 Foster: Diabetes Mellitus, p. 188. 



DIABETES MELLITUS 469 

In all but these very mildest cases it is necessary as the 
first step, to determine the individual's carbohydrate tol- 
ance. This is done by gradually reducing the patient's 
carbohydrate allowance until after about five days they are 
put on a standard strict diet containing only 15 gm. of car- 
bohydrate in the green vegetables allowed. To this is added 
a definite carbohydrate allowance in the form of white bread 
(55 P er cent, carbohydrate), Huntly and Palmer biscuits, 
5 gm. Uneeda biscuit, 4.6 gm. carbohydrate each. 

A convenient method is to allow with the Standard Strict 
Diet 25 gm. carbohydrate in any one of these three forms, at 
each meal, testing the urine of the second twenty- four hours. 
If it still contains sugar, reduce the carbohydrate allowance 
one-half and so by a process of reduction or addition, in case 
the tolerance is over the 75 gm. carbohydrate, the point at 
which sugar just fails to show in the urine is reached. The 
amount of carbohydrate that will accomplish this constitutes 
the carbohydrate tolerance. When this is determined the 
patient is put on a diet which contains not over one-half the 
tolerance. The reason for this being that while the urine may 
become sugar-free on the full tolerance, the hyperglycemia 
does not disappear so easily and ordinarily needs a greater 
reduction in the carbohydrate to reduce this to normal. 
After the patient has been on this tolerance for some weeks 
it is safe to gradually increase the amount of carbohydrate 
and determine its utilization by frequent urinary tests. In 
this way over a period of months by resting the disturbed 
function it is usually possible to materially increase the 
amount of carbohydrate beyond the original tolerance and 
gradually bring the patient up to an improvement which allows 
of a fair diet. In order to vary the diet as much as possible 
it is necessary to know the actual carbohydrate content of 
the different foodstuffs and to construct a diet that shall not 
be monotonous. The use of the table of carbohydrate 
equivalents will materially aid in doing this. One prerequisite 
of success is the actual weighing of the foods, in the mild 
cases only of the carbohydrate foods, in the more severe the 
protein and fats must also be weighed. 
Standard Strict Diet: 

Breakfast: Eggs, two; ham, 90 gm. (3 oz.) ; coffee (with- 
out sugar) ; butter, 15 gm. (}4 oz.), this used on bread 
or biscuit; if no carbohydrate is allowed, cooked in 
with the eggs; cream, 45 c.c. (lyi oz.). 
Luncheon: Meat (chops or steak), 120 gm. (4 oz.); 
green vegetables allowed from list, 2 tablespoonfuls; 
wine, white or red (2 claret glasses), 6 ounces, or 



470 DISTURB A NCES OF NORMAL METABOLISM 

brandy or whiskey (2 tablespoonfuls) 1 ounce; butter 
15 gm. (i/2 oz.), cooked with the vegetables or on 
bread if allowed. 

Afternoon tea with 15 gm. {}/i oz.) cream (no sugar). 

Dinner: Clear soup; fish, 90 gm. (3 oz.); meat (fowl, 
beef or mutton), 120 gm. (4 oz.) ; green vegetables, 
2 tablespoonfuls (see list); salad, with 15 gm. i}/i oz.) 
of oil with dressing; cream cheese, 30 gm. (1 oz.); 
red or white wine or whiskey as at luncheon; coffee, 
small cup; butter, 30 gm. (1 oz.) on the fish, meat or 
green vegetables in case no bread is allowed. 

Bedtime: A cup of bouillon with a raw egg. 
This represents: Protein, 112 gm. (3% oz.) ; nitrogen, 18 
gm. (270 grains); fat, 160 gm. (5^ oz.); calories, 2200. 
Standard Diet with Restricted Protein. 

Breakfast: Eggs, two; bacon, 15 gm. {}/% oz.) ; coffee, 
with cream, 45 gm. (ij^ oz.) ; butter, 20 gm. (% oz.). 

Luncheon: Egg, one; bacon, 15 gm. (^ oz.); meat (ham 
steak or chops), 60 gm. (2 oz.); salad, with 15 gm. 
(3/2 oz.), oil for dressing; wine, white or red, 2 claret 
glasses, 180 c.c (6 oz.), or whiskey or brandy, 2 table- 
spoonfuls, 30 c.c (1 oz.); butter, 40 gm. (ij^ oz.). 

Afternoon tea with 15 gm. i}/i oz.) cream. 

Dinner: Clear soup; meat (mutton, beef, turkey or 
chops), 90 gm. (3 oz.); vegetables from list, 2 table- 
spoonfuls; salad with 15 gm. (}/2 oz.) oil; cream cheese 
30 gm. (1 oz.); wine, red or white, 2 claret glasses, 
180 c.c. (6 oz.) or whiskey or brandy as at luncheon; 
coffee; butter, 30 gm. (1 oz.). 

Bedtime: Bouillon with one egg. 
This represents: Protein, 70 gm. {2% oz.) ; nitrogen, 10 
gm. (150 grains); fat, 180 gm. (6 oz.) ; calories, 2500. 
Green Days : 

Breakfast: Egg, one; cup of coffee, without cream or 
sugar. 

Dinner: Spinach with one egg, hard-boiled; bacon, 15 
gm. i}/^ oz.); salad, with 15 gm. (J/£ oz.) oil; wine, 
red or white, 250 c.c. (8 oz.) or whiskey or brandy, 
30 c.c. (1 oz.). 

4.30 p.m. Cup of broth or beef tea. 

Supper: Egg, one, best scrambled with a little tomato 
or butter; bacon, 15 gm. [}/i oz.) ; cabbage, sauer- 
kraut, string beans, cauliflower or asparagus; wine, 
red or white, whiskey or brandy as at dinner. 
Give 15 to 30 gm. (H to 1 oz.) of bicarbonate of soda in 
the twenty-four hours. This diet represents the following 



DIABETES MELLITUS 471 

values: Protein, 32 gm. (1 oz.) ; nitrogen, 5 gm. (75 grains); 
carbohydrate, 5 gm. ( % oz.) ; fat, 65 gm. (2 oz.) ; calories, 

575- 

In any of these diets if there are reasons for not using 
bacon, beef 30 gm. (1 oz.) may be substituted for it. 

Oatmeal Days: 

Porridge made from oatmeal, 250 gm. (8 oz.) ; butter, 250 
gm. (8 oz.), salt and pepper. The oatmeal should be boiled 
all night in a double boiler with the butter and whites of six 
eggs added next morning. 

"This constitutes the food for one day and may be eaten 
as gruel, mush or fried mush, divided into seven equal parts, 
one part to be taken every two hours." Two cups of black 
coffee and 180 c.c. (6 oz.) of red or sour white wine or 30 c.c. 
(1 oz.) of whiskey or brandy may be taken during the day. 

This represents: Protein, 63 gm. (2 oz.) ; nitrogen, 16.8 
gm. (J/2 oz.); carbohydrate, 170 gm. (5%oz.); fat, 212 gm. 
(7 oz.) ; calories, 3300. 

General Diabetic Diet List. 

May take — Soups: Meat soups and broths. Egg, cheese 
or allowed vegetables may be added. 

Meats: All kinds of fresh, smoked and cured meats (ex- 
cept liver), poultry. Pate de fois gras, no sauces that con- 
tain flour. 

Fish: Every kind (except shell fish), dried, fresh, smoked 
or pickled. 

Egg: Cooked in any style but without flour. 

Fats: Lard, butter, oils, suet. 

Cheese: Swiss, English, cream, pineapple cheese. 

Vegetables: Cabbage, cauliflower, celery, chicory, cress, 
asparagus, beet tops, sprouts, cucumber, eggplant, endive, 
lettuce, Kohlrabi, okra, pumpkin, radish, rhubarb, sauer- 
kraut, spinach, tomatoes, string beans, vegetable marrow. 

Salads and Pickles: Made of above vegetables, unsweet- 
ened. 

Mushrooms and truffles. 

Cream: If allowed in tolerance, 90 c.c. (3 oz.) per day. 

Condiments: Pepper, salt, curry, cinnamon, mustard, nut- 
meg, caraway, capers, vinegar. 

Desserts: Custards, ice-cream, ade mwith eggs and cream. 
Lemon water-ice, jellies made with gelatin. No sugar to be 
used but saccharine only for sweetening and flavored with 
brandy, coffee, vanilla or lemon. 

Beverages: Tea, coffee sweetened with saccharine. Whis- 
key or distilled liquor, 150 c.c. (5 oz.). Red or white wine 
(sour) up to 500 c.c. (1 pint) per day. 



472 DISTURB A NCES OF NORMA L ME TA BOLISM 



Foods Prohibited Except as Allowed in Accessory Diet: 

Sugars or sweetening other than saccharine, saxin, garan- 
tose, dulcin. 

Puddings, preserves, cake, pastry or ice-cream. 

Bread, biscuit, crackers, toast, etc. 

Cereals of all kinds, macaroni, potatoes, or other under- 
ground vegetables, as carrots, parsnips, beets, turnips, also 
beans, peas and corn. 

Fruit, fresh or dried. 

No flour allowed in soups or gravies. 

Ale, beer, porter, sweet wines, sparkling wines, cider, milk, 

chocolate, cocoa, sweet drinks, liquor. 1 

Table of Carbohydrate Equivalents. 
Carbohydrate equivalents. 
White bread: 



Grams 




4 
i 


8 


16 


25 
6 


32 
8 


40 
10 


Drams ..-.*... 




2 


4 






Equals 












Potato 


. Gms 


. 22 


44 


88 


132 


176 


220 


Hominy (cooked) 


" 


25 


50 


100 


150 


200 


250 


Oatmeal (cooked) 


" 


40 


80 


160 


240 


320 


400 


Rice (cooked) . . 


a 


15 


30 


60 


90 


120 


150 


Farina (cooked) . 


it 


25 


50 


100 


150 


200 


250 


Shredded wheat . 


a 


5 


10 


20 


30 


40 


50 


Indian-meal mush . 


it 


27 


54 


108 


162 


216 


270 


Macaroni .... 


a 


30 


60 


120 


180 


240 


300 


Corn bread . . . 


a 


10 


20 


40 


60 


80 


100 


Barker's gluten food, A 


tt 


102 


204 


408 


612 


816 


1020 


Barker's gluten food, B 


it 


74 


148 


296 


444 


592 


740 


Barker's gluten food, C 


a 


54 


108 


216 


224 


432 


540 


Almond meal 


a 


65 


130 


260 


390 


520 


650 


Gum gluten (ground) 


" 


12 


24 


48 


72 


96 


120 


Soja-bean meal . 


a 


50 


100 


200 


300 


400 


500 


Casoid flour . 


it 


55 


no 


220 


330 


440 


550 


Pure gluten biscuit . 


tt 


50 


100 


200 


300 


400 


500 


Protopuff No. I . 


it 


45 


90 


180 


270 


360 


450 


Protopuff No. 2 . 


it 


12 


24 


48 


72 


96 


120 


Salvia sticks . 


it 


25 


50 


100 


150 


200 


250 


Milk (whole) . . 


a 


112 


224 


448 


672 


896 


1 120 


Cream .... 


a 


112 


224 


448 


672 


896 


1 120 


Grapefruit weighed witt 


i skin " 


187 


375 


750 


1125 


1150 


1875 


Rice pudding 


a 


14 


28 


56 


84 


112 


140 


Tapioca pudding 


it 


15 


30 


60 


90 


120 


150 


Beets (cooked) . 


" 


65 


130 


260 


390 


520 


650 


Custard (baked) . . 


a 


3° 


60 


120 


180 


240 


300 


Carrots .... 


a 


65 


130 


260 


390 


520 


650 


Corn (canned or green) 


tt 


22 


44 


88 


132 


176 


220 


Egg plant . . . 


a 


90 


180 


360 


540 


720 


900 


Parsnips .... 


it 


35 


70 


. 140 


210 


280 


350 


Green peas . 


a 


30 


60 


120 


180 


240 


300 


Turnips .... 


a 


56 


112 


224 


336 


448 


560 


Baked beans . 


a 


22 


44 


88 


132 


176 


220 


Apples .... 


tt 


45 


90 


180 


270 


360 


450 



Thus 4 gms. of white bread (by which the tolerance was determined) contains 
the same amount of carbohydrate as do 22 gms. of Potato, 40 gms. of Oatmeal, 
30 gms. of Macaroni, etc. 

1 These diets are adapted from Janeway, in Musser and Kelly's Therapeutics. 



DIABETES MELLITUS 



473 



Equal: 



Bananas .... 


Gms. 20 


40 


80 


120 


160 


200 


Oranges .... 


. . " 40 


80 


160 


240 


320 


400 


Peaches .... 


• • . " 50 


100 


200 


300 


400 


500 


Pears 


. . " 50 


100 


200 


300 


400 


500 


Prunes .... 


• • " 24 


48 


96 


144 


192 


24O 


Watermelon . 


• • " 225 


450 


900 









n. = 4 gm. 


carbohydrate 


' = 4 " 


" 


' = 4 " 


" 


' = 2 " 


" 


' = 2 " 


i < 


' = 16 " 


<« 



[Method of using the table of carbohydrate equivalents; 
Take for example a case with a carbohydrate allowance of 
32 gm. (1 oz.). 

Proto puff No. 1 45 gm 

Potato 22 

Oatmeal 40 

Beets 33 

Orange 40 

Rice pudding 56 

236 " = 32 " 

Fosters System of Carbohydrate Units. — For the milder 
grades of the disease Foster has devised a system of carbo- 
hydrate units, each unit representing 10 gm. of carbohydrate. 
Of course these quantities are not absolutely accurate but 
are approximately so and when the tolerance has been de- 
termined the allowance of carbohydrate can be conveniently 
taken from this table without weighing, the patients learning 
soon to remember the units. 1 

Soups: 

Bean Average portion equals 1 unit 

Clam chowder " " 

Cream of corn 

Pea puree " " 

Potato 

Vegetables: 

Beans, baked 2 tablespoonfuls 

Beans, butter 2 

Beans, lima 2 

Beans, kidney 2 

Beets 2 

Corn, canned 2 

Corn, green 1 ear 

Onions 2 onions 

Green peas 2 tablespoonfuls 

Potato, baked 1 medium-sized 

Potato, boiled 1 " 

Potato, mashed 2 tablespoonfuls 

Fruits: 

Apple 1 medium-sized 

Blackberries 2 tablespoonfuls 

Cantaloupe One-half 

Currants 3 tablespoonfuls 

Huckleberries 2 " 

Orange 1 medium-sized 

Peach • . . . 1 " 

Pear 1 

Plum .2 

Raspberries 3 tablespoonfuls 

Strawberries 4 " 

1 Foster: Diabetes Mellitus, p. 201. 



" I 


« 


" I 


" 


" I 


<< 


" 2 


units 


" I 


unit 


" 2 


units 


" 2 


" 


" I 


unit 


" 2 


units 


" 2 


11 


" I 


unit 


" 2 


units 


" 3 


" 


14 2 




" 2 


" 


" 1 


unit 


" 2 units 


" 1 


unit 


" 1 


" 


" 2 


units 


" 1 


unit 


" 2 


units 


" 1 


unit 


" 1 


" 


" 1 


it 



474 DISTURB A NCES OF NORMA L ME TA BOLISM 

Cereals: 

Bread Slice 3 X4X J^'m. Equals 2 units 

Hominy, boiled 1 tablespoonful " 1 unit 

H. 0. (oatmeal), boiled .... 2 tablespoonfuls " 1 " 

Macaroni, boiled 2 " "2 units 

Macaroni, baked with cheese ... 2 " " 2 " 

Oatmeal, boiled 2 " 1 unit 

Rice, boiled ........ 1 "2 units 

Shredded wheat biscuit . *. 1 biscuit " 2 " 

Spaghetti, baked with tomato ... 2 tablespoonfuls " 2 " 

Sample Diet. 

Sample Diet (six units allowed, i. e., 60 gm. carbohydrate) : 
Breakfast: Bacon and eggs; cereal (equal to 1 unit), 

with tablespoonful of cream. 
Lunch: Clear soup; meat and green vegetable; bread, 

yi slice (1 unit); mashed potato (2 units). 
Dinner: Soup; meat and green vegetable; baked beans 
(2 units) ; salad and cheese. 

Foster suggests that this table of units should not be used 
when the glycosuria is over 70 gm. 

Procedure in the Medium Severe Cases (over 50 gm. glu- 
cose in urine). — If the case has no carbohydrate tolerance 
and does not become sugar-free on the Standard Strict Diet 
without added carbohydrate, the next step is to put the case 
on the Standard Strict Diet with restricted protein. If 
after two or three days the glycosuria does not clear up, put 
on two green days, then back on Standard Strict Diet with 
restricted protein for a few days. If this results in freeing 
the urine of glucose then the regular Standard Strict Diet 
may be used and if the urine still remains sugar-free it may 
be possible to add carbohydrate, preferably in the form of 
green vegetables as recommended by Joslin, using weighed 
amounts of vegetables containing 5, 10, 15 or 20 per cent, of 
carbohydrate (p. 481). These are ordinarily better borne 
than any form of bread or biscuit, although bread may be 
tried tentatively in definite, small amounts. Often this 
routine will result in freeing the urine of sugar and with care 
a certain amount of carbohydrate tolerance may be developed, 
but in any case the total amount of carbohydrate allowed 
should be kept distinctly below the point of tolerance for 
the reasons already explained. 

In these cases the use of the table of carbohydrate equiva- 
lents or Foster's carbohydrate units will be found useful. 

Severe Cases with Marked Ketonuria. — The best plan is to 
put the patients at once on the oatmeal diet for several days, 
two to ten, without regard to the sugar in the urine, at the 
same time giving considerable amounts of bicarbonate of 
soda, enough to render the urine alkaline, which should be 



DIABETES MELLITUS 475 

attained if possible. If the acidosis diminishes but the sugar 
content of the urine remains high, patients are often bene- 
fited by two green days and from this to the Standard Strict 
Diet with restricted protein, then the full Standard Strict 
Diet, if the acidosis remains in control. 

Von Noorden recommends what he calls a "set of days" 
consisting of two days restricted protein diet, two days of 
green diet and three days of oatmeal diet. We then return 
to the restricted protein diet or even full protein, but if 
sugar again appears the "set" is repeated. Often the 
patients become sugar-free and acid-free on this plan when a 
little carbohydrate can again be tried, preferably in vege- 
table form. 

When the acetonuria is extreme or coma threatens, von 
Noorden found "alcohol days" of great benefit and recom- 
mends giving 90 to 150 c.c. (3 to 5 oz.) of whiskey daily well 
diluted and no food. This often diminishes the ketonuria 
and the general condition is much improved. The alcohol 
diet is limited to one or two days and then the oatmeal days, 
etc., are again tried as before. This is practically a fasting 
cure and in some form has been found by many observers 
to be of great service under these conditions. 

Instead of using oatmeal some clinicians prefer to use 
potato days or bread-and-butter days, or as Falta recom- 
mends, a rotation of the different starchy foods taking one 
at a time. 
Potato Diet: 1 

Breakfast: One baked potato with butter; one cup of 

coffee, cream, 25 c.c. (1 oz.). 
Luncheon and Dinner: Potato boiled, butter; green vege- 
table; whiskey or wine. 
Bread-and-Butter Diet: 2 

Breakfast: Two pieces of bread or toast, buttered; 

yolks of two eggs, cooked. 

Luncheon and Dinner: Two slices of bread and butter; 

green vegetable, with oil or egg sauce; a rasher of 

bacon; wine, whiskey or coffee. 

Allen's Treatment of Diabetes Mellitus. — This treatment, 

based on results of extensive animal experimentation, has 

only been used for human diabetes during the past three or 

four years and although apparently very successful it has 

not as yet stood the test of time nor has it been used long 

enough to judge of the late results years after treatment was 

begun. As already stated in this form of treatment emphasis 

Foster: Diabetes Mellitus, p. 186. 
2 Loc. cit. 



476 DISTURBANCES OF NORMAL METABOLISM 

is placed upon an initial fast period sufficient to clear up the 
glycosuria and acidosis, if that is present, and it has been 
found practically without exception that fasting from two 
to ten or twelve days at the outside will accomplish these 
ends. 

As Allen says in speaking of this treatment in dogs: "It 
was found that the grave condition of diabetes yielded to an 
initial fast of days or weeks with a subsequent diet which 
kept the animals at a low level of weight and metabolic 
activity. Anything that tended to increase the weight or 
metabolism brought back the glycosuria and acidosis. If 
the animal was allowed to go down by glycosuria with emaci- 
ation, weakness and death, it was found that degenerative 
changes took place in the islands of Langerhans and if this 
decline was prevented the islands remained intact." 

The two cardinal points in Allen's treatment are: 

1. An initial fast to the point of clearing up the glycosuria 
accompanied by a reduction in weight which should be 
permanent. 

2. The subsequent diet which does not allow of a return of 
the glycosuria but if by chance there is a return an immediate 
fast day or two is given to clear it up again. 

Before speaking in detail of the method, it is necessary to 
emphasize one point upon which Allen lays great stress and 
which is entirely contrary to the older teachings, namely, 
that a loss of weight is of distinct advantage, as it tends to 
increase carbohydrate tolerance and makes the patients feel 
much better, which suggests the possibility that the weakness 
and many of the other symptoms are due to an intoxication 
and more than likely from the unexcreted end-products of 
protein metabolism. If these patients are made to gain by 
adding fats to the diet or trying to give larger amounts of 
food, as is the custom with the older forms of treatment, at 
once glycosuria and the acidosis returns. This loss of weight 
is of course of greatest benefit in those cases who are rather 
overweight to begin with, but even the moderately well- 
nourished or spare individuals bear the fast advantageously 
with the consequent loss of weight, although surprisingly 
enough the diabetic does not seem to lose weight as rapidly 
as in starvation of the normal man, due to the fact that a 
certain amount of energy is derived from the burning of the 
ketone bodies. As in severe diabetes there is more or less 
of a breakdown all along the line, Allen urges limiting the 
total caloric intake and the body mass to correspond to the 
assimilative function. He therefore warns against efforts 
to maintain patients on a high level of diet or weight. 



DIABETES MELLITUS 477 

In a few cases the starvation causes alarming symptoms of 
nausea and vomiting which disappear on feeding and when a 
second fast is instituted, after a few days or a week or two, 
these patients stand it perfectly well and become sugar- free. 
The old theory that a dangerous acidosis is engendered by a 
prolonged fast has absolutely to be given up as untrue. 

During the fasting period, the patients being kept in bed, 
are allowed the following diet: 

Whiskey, black coffee, bouillon, water, tea. Thrice-cooked 
green vegetables (whereby all starch is removed) may be given, 
but are not a necessary part of the diet in the period of starv- 
ation. They merely give a sense of fulness to the patient. 

The whiskey given in amounts of 50 to 120 c.c. per day 
(1 % to 4 oz.) is not an essential part of this period but may be 
used and if so furnishes 7 calories per c.c. It has no influence 
on sugar formation and aside from this the other articles 
allowed have practically no food value. (Whiskey is said not 
to have any influence on acetone formation in normal indi- 
viduals.) 1 

Twenty-four to forty-eight hours after the urine becomes 
free of glucose, cautious feeding is begun, individualizing the 
diet as much as possible, but it is absolutely essential that 
the patient remain sugar- and acid-free. In the feeding, 
one usually begins by using carbohydrates most easily by 
prescribing 100 to 200 gm. (3^ to 6% oz.) of green vege- 
tables (cooked once) of the 5and 10 per cent, classes accord- 
ing to Joslin's classification. (See page 481). 

This is increased in amount daily until possibly a trace of 
glucose appears which is at once cleared up by a fast day. 
This marks the patient's carbohydrate tolerance. Next the 
protein tolerance is determined in the same way by giving 
the whites of one or two eggs, then meat is added until either 
glycosuria appears or the patients reach a fair, physiological 
protein allowance, or one tests the protein tolerance first, 
then the carbohydrate ; in either case in finding the tolerance 
only one food element is used at a time, protein or carbohy- 
drate. If for example in a given case we were to have a pro- 
tein tolerance of 60 gm. (2 oz.) protein and 20 gm. ( % oz.) 
carbohydrate, such a patient would be put on a diet with 
probably 50 gm. protein and 10 gm. carbohydrate which is 
gradually increased. In other words, just as we saw in the 
von Noorden regimen, the patients do best when they are 
allowed only about one-half their carbohydrate tolerance at 
first, which can be gradually increased. 

1 Jour. A.m. Med. Assn., September 9, 1916, p. 84. 



478 DISTURBANCES OF NORMAL METABOLISM 

Geyelin's method of using the Allen treatment in the 
Presbyterian Hospital, New York is somewhat as follows: 

The patient is arbitrarily placed on a low caloric diet con- 
sisting of 15 gm. i}/i oz.) carbohydrate; 30 gm. (1 oz.) 
fats; 30 gm. (1 oz.) protein (diet No. 1). This is con- 
tinued for a few days to determine the effect of this low food 
intake in overcoming the glyosuria. This is a more agree- 
able diet than a virtual fast, but if after from one to four 
days of this diet the glycosuria is not decreasing or is per- 
haps increasing a definite fast is instituted (diet No. 2). As 
soon as the patient is free from sugar, a diet of from 10 to 
20 gm. (}/& to % oz.) carbohydrate is given with 30 gm. 
(1 oz.) protein and 30 gm. (1 oz.) fat. Keeping the carbo- 
hydrate at a constant level (10 to 20 gm.) the protein and fat 
are increased 10 gm. (J^ oz.) daily, until sugar appears, or 
until the protein intake has reached a level of i}4 gm. 
(22 gr.) per kilo of body weight and the fat 100 to 150 gm. 
(3M to 5 oz.). If on this diet the patient is still sugar-free 
the carbohydrate is increased 10 gm. [y z oz.) daily until 
sugar appears in the urine, a fast day is then given. After 
the urine is again clear of sugar, the diet is arranged with the 
same protein and fat content, but with only one-half to two- 
thirds the carbohydrate tolerance as determined by the point 
at which we found the patient " spilled" sugar in the urine. 

If glycosuria appears while the patient is on a fixed low 
carbohydrate diet and while the protein and fat are being 
increased, a fast day is given; following the fast the protein 
and fat intake is lowered from 10 to 20 gm. (J/3 to % oz.) 
and kept constant while the carbohydrate is gradually in- 
creased 5 gm. (75 gr.) daily until glycosuria again appears. 
Another fast day is then given after which the increase in 
protein and fat is again begun as before. Later the carbohy- 
drate is also gradually increased 10 gm. (J^ oz. a day). 

For the most part the increase in carbohydrate is best 
made with once boiled vegetables, at first of the 5 per cent, 
class and later of those with higher percentage of carbohyd- 
rate. It is not until the carbohydrate tolerance is consider- 
able that we allow any actual starch in the form of bread or 
bread substitutes. 

The increases in diet can be worked out most conveniently 
from the food tables (pp. 671 and 677) 

In the more severe cases with only moderate acidosis at 
most, the patient's diet is gradually decreased in carbohy- 
drates until after a few days they are fasted and put on diet 
No. 2 or No. 1. This results as a rule, in converting a severe 
into a moderately severe case. 



DIABETES MELLITUS 479 

If coma is impending, the best plan is to give the patient 
a plain saline infusion into the vein and urge them to take 
from 5 to 10 gm. (H to H oz.) of salt by mouth with the idea 
of inducing a subcutaneous edema and so storing the ketone 
bodies in the tissues. In addition glucose is given by mouth, 
particularly if the patients have been starved of carbohy- 
drates. 

After the danger of coma is passed the cases are treated 
as are those of medium severity. 

Standard Strict Diet (Geyelin). 
Diet Xo. i : 

15 gm. carbohydrate, 30 gm. fat, 30 gm. protein. 
Breakfast: 

2 eggs. 

1 cup coffee, 200 c.c. (6}4 oz.) and saccharin, no cream. 
Luncheon: 

Tomatoes (fresh) 200 gm. (6>< oz.) (7.8 gm. (117 gr.) carbohydrate). 

Broth. 200 c.c. (6K oz.). 
3 P. M.: 

W hite of one egg. 

Broth, 200 c.c. (6}4 oz.). 
Supper: 

String beans (canned), 200 c.c. {d x / 2 oz.); 7.2 gm. (108 gr.) carbohydrate. 

Butter, 7 gm. {% oz.). 

Two eggs. 

One cup of tea, no cream. 
Xext day 25 gm. ( 5 6 oz.) carbohydrate. 

To increase diet Xo. i, 10 gm. carbohydrate add 250 gm. 
(8 oz.) cooked beans at luncheon (once boiled). 

For the following day 35 gm. (1% oz.) carbohydrate. 
To increase 10 gm. (150 gr.) more carbohydrate add 180 gm. 
(6 oz.) of once boiled cabbage at 3 r.M. Feeding. 

For 45 gms. (i 1 ^ oz.) carbohydrate add 250 gm. (8 oz.), 
raw or canned tomatoes for breakfast. For 55 gm. (if 
oz.) carbohydrate add 180 gm. (6 oz.) cabbage. 

All vegetables are to be served salt-free. 

Diet for Fast Day. 
Diet Xo. 2: 
Breakfast: 

Cup of coffee, 200 c.c. (6^2 oz.), saccarin. 

Xo milk or sugar. 

Thrice cooked 5 per cent. Yegetables. 

200 gm. (6}4 oz.), e. g., string beans, spinach, cauliflower, etc., with vinegar 
Q.S. 
Mid. A. M.: 

Salt-poor broth, 200 c.c. {6}4 oz.). 
Luncheon: 

Salt-poor broth, 200 c.c. (6,K oz.). 

Cup of tea or coffee, 200 c.c. (6K oz.) or more if desired. 

5 per cent, vegetables, 200 c.c. (6K oz.). 

Whiskey or brandy, 30 c.c. (1 oz.) if desired. 
Supper: 

Same as luncheon. Using other of the 5 per cent, vegetables. 
Bed-time: 

Salt-poor broth. 

Water. 



480 DIST URBA NCES OF NORMA L ME TA BOLISM 

In those cases accompanied by old age, obesity or nephritis, 
it is better to omit the initial fast at first and put them 
directly on a 15 130 130 food formula (diet No. 1.), as food 
fasting sometimes causes these patients to pass rapidly into 
coma. If this brings about a sugar-free urine, that is favor- 
able, if not, then it may be advisable to try a fast, watching 
the ketonuria carefully. 

Allen says that "fat is less urgently needed except in very 
weak and emaciated patients and can be added gradually." 1 
In the severe cases it is necessary to test in this way the toler- 
ance for all classes of foods, carbohydrate, protein and fats 
one at a time. Carbohydrate is given if possible, but is 
kept safely below the limit of tolerance. Protein must be 
kept fairly low, sometimes very low. With a dangerously 
low protein tolerance the working rule has been to exclude 
all carbohydrate, then feed as much protein as possible with- 
out glycosuria. Experience seems to indicate that every 
patient can tolerate his necessary minimum of protein and 
that glycosuria appears only when this is exceeded. The 
severe diabetic is often thin and weak because he cannot 
metabolize enough food to be strong and well, but as long as 
his weakened function is not overtaxed he seems to be able 
to retain such weight and strength as he has, at least for a 
considerable period. Any attempt to build him up with 
any kind or quantity of food beyond that which he is able 
to metabolize perfectly, apparently hastens a fatal result. 2 

The mild or moderately severe cases are usually c eared of 
their glucose and acetone with a fast of one or two days, the 
subsequent period of observation being devoted to an educa- 
tion of the patient in food values (after determining the car- 
bohydrate tolerance), for these cases can usually take a full 
allowance of protein and fat. With the really severe cases, 
of course, the intitial fast is usually necessarily of longer 
duration and with no carbohydrate tolerance the feeding of 
the proper amount of protein becomes a nice problem. With 
perseverance, almost all the cases can be taken along to a 
point where they can take their minimum of protein, some 
fat and later probably a little carbohydrate which if the 
progress be fortunate, may be gingerly increased. 

There is still a small class of cases that resist every effort 
at reaching a maintenance diet and who must inevitably 
perish of their disease, fortunately these are few and the 
favorable reports of Allen's treatment makes it seem probable 
that they may be still further reduced in numbers. 

1 The Treatment of Diabetes, Boston Med. and Surg. Jour., February 18, 1915. 

2 Loc. cit. 



DIABETES MELLITUS 



481 



The best results in this treatment are naturally obtained 
in hospitals or sanatoriawhere everything is readily controlled ; 
but Geyelin has had marked success with this treatment 
in ambulatory cases at the Vanderbilt Clinic, New York 
City. The patients are taught when leaving the hospital 
how regularly to examine their own urine with Benedict's 
solution and to take one fast day every seven, ten or four- 
teen days, according to the severity of the case when under 
treatment. 

Allen recommends exercise in the cases which reach a fair 
tolerance, not only light but very active and vigorous exer- 
cises, as tending to keep the patients in better physical condi- 
tion and actually increasing carbohydrate tolerance. One 
fact needs repetition, when after a fast of eight to ten days 
the urine does not become sugar and acid-free it is well to 
give a food protein in small amount, 30 to 50 gm. (1 to 1% 
oz.). This usually increases the sugar, but if after a day or 
two of this diet a fast is again instituted the urine usually 
becomes promptly sugar- and acid-free. This is shown by 
the illustrative case on January 20th to 23d, although of 
course this is not a severe type of case, as it serves well for 
the illustration of the method and of charting. A separate 
sheet is kept on which the actual foods and their amounts 
are recorded. 

The following short resume of Allen's treatment given by 
Joslin 1 is of value for its clearness and forms a good working 
basis for those wishing to use this treatment. 

Strict Diet. Meats, Fish, Broths, Gelatin, Eggs, Butter, Olive Oil 
Coffee, Tea and Cracked Cocoa. 



(Foods Arranged Approximately According to 


Per Cent, of 


Carbohydrates.) 


Vegetables, 








5 per cent. 


10 per cent. 


IS per cent. 


20 per cent. 


Lettuce 


Cauliflower 


Onions 


Green peas 


Potatoes 


Spinach 


Tomatoes 


Squash 


Artichokes 


Shell beans 


Sauerkraut 


Rhubarb 


Turnip 


Parsnips 


Baked beans 


String beans 


Egg plant 


Carrots 


Canned lima 


Green corn 


Celery 


Leeks 


Okra 


beans 


Boiled rice 


Asparagus 


Beet greens 


Mushrooms 




Boiled 


Cucumbers 


Water cress 


Beets 




macaroni 


Brussels 


Cabbage 








sprouts 


Radishes 








Sorrel 


Pumpkin 








Endive 


Kohl-rabi 








Dandelions 


Broccoli 








Swiss chard 


Vegetable 








Sea kale 


marrow 









31 



1 Am. Jour. Med. Sc, 1915, cl, 492. 



482 DISTURB A NCES OF NORMA L ME TA BOLISM 





to 

3 

8 

c 

rt 

iS 
u 
in 

i 






£ u 
.2 c 


£ 6 
.2 o 


>^ 6 




Whiskey, 

90 c.c. 
Pro. 20; 

whiskey,- 
90 c.c. 


Whiskey, 

90 c.c. 
Pro., 20; 

whiskey. 


6 

CO 

6 


Pro., 50. 
Pro., 70. 
Pro., 90. 


Pro., no. 
r a thrice cooked 

gms. given. Par- 
ste 3 b veg." 

Fat C. H. 

20 


T3 c. 

go 

so 




CO 

CO 






m 

so 

oo 
CO 






Os 

Os 
co 




10 

CO 




Os 
CO 


0? o« 
."° bel^ O 

• co > p -J a^ •" 

03 Ui 


n 


o 


o5 


o 

03 




o 
o3 


• -o 


6 6 

a 03 


+» 

fe 03 03 


O 

03 


6 6 ^ 6 r - M 

nj a3 fc a3 fe 


03 • csfe 03 


1 

3 


VO cosO co 


-a 
aj 


OX) o3 +j 


"\0 


*d 

IS 


-v -d 


^ 53 " 53 


T3 *d *d *D 

^ 53^ 53^ 53^ 53^ 
^ ^ ^ £ 


"O -O *0 T) 

CU D CU (U 

53 ^ 53 ^ 53 ^ *53 
^ ^ £ £ 




^5" 

co 


CO 

o 


^1- 


Os 
fO 


o 

CM 

4 


lO 

CM 


Os 

O) Os 

CM HH 


Os Os 

IM lO 

CN CS1 


10 




00 
CO 




CM 


M 




2* 


m 

CM 


CO 
<si 


CM 
iO 


SO 


C? 


























13 d 

H 3 




cm 

o 

On 


oo 




00 

6 


Os 
vO 


oo 
f^ O 

CO hi 

r^ 10 


O M 

00 t^ 


CO 
10 


Os 




O 






X 


> 


X 


X 
X 


X 
X 


H 


H H 


X X 
X X 


X 
X 


X^" X X 


> > > > 

X X X X 


_ °5 
IftS 


o 


o 


iO,s r« "0-= o3 

■O o3 o co o3 u 


"0-^ 03 

CO 03 U 


ioii o3 sO 

CO 03 O CI 




CO 0— ' 

O) i- 03 

1-1 O- u 


O E 00 so £ 

cm p_ cs co a, 


(1 

10 *-l 


i 

8 

3 

a 

3 

o 




CM 

00 


3s 
CO 

(sj 


Cs 


-*• 


O 

6 


8* 

H ° 


& > 








00 


: : 


ss 


O 
+ 


+ 


+ 


+ 


+ 










o<^~ 


Hfe'^ ° ° 


1 '-> 








VO 






1^. 

VO - lO 


CN 














2-^ 

— ' u 


+ 


O 


+ 


+ 


+ 


H 


£ di 


H H 


H 


£ h'°"- 


0000 


i 6 
<2 




£ 


+ 


+ 


+ 
+ 


£^ 








+£^h v -£ 


t£b 0^^ 


£& 


o 


CM 


Os 


od- 


Tt" 


o 


co rj- 


co lO 





lO lO lO^. 00 


rv. JJ -m « 


2. 5 d 
> 


o 

00 


OS 

co 


Os 


co 


o 

o 
<* 


o 

co 
00 
CO 


O 10 

Os CN 

fSl M 
O) CO 


O O 
(N O 

rf ON 



-<* 

so 




H CO 1 
00 CO T^ 
CM 01 


O uo O O 
CN CO SO (N 
Tf CO so t^ 
fsl CO CM "H 








T 

1/3 




CO 


Os 

oo 


o 

M 

1 
Os 


H-l CS< 

<N rsi 

1 l 

O 


co n- 

CN CM 

1 1 
M CO 

cm n 


10 


VO t^ 00 
CN N CM 
1 1 1 
10 so r^ 

(M (M M 


Os O •-> ^, M 
(M co cO-£ , 

00 Os Otl - 
<N CM CO CO 



DIABETES MELLITUS 



483 



Fruits 
Ripe olives 

(20 per cent, iat) 
Grapefruit 



Nuts 
Butternuts 
Pignolias 



Lemons 


Apples 


Plums 


Oranges 


Pears 


Bananas 


Cranberries 


Apricots 




Strawberries 


Blueberries 




Blackberries 


Cherries 




Gooseberries 


Currants 




Peaches 


Raspberries 




Pineapple 


Huckleberries 




Watermelon 






Brazil nuts 


Almonds 


Peanuts 


Black walnuts 


Walnuts (English) 


Hickory nuts 


Beechnuts 




Pecans 


Pistachios 




Filberts 


Pine nuts 


40 per cent 
Chestnuts 



Miscellaneous: Unsweetened and un- Reckon actually available carbohy- 
spiced pickles, clams, oysters, scallops, drates in vegetables of 5 per cent, 
liver, fish roe. group as 3 per cent., of 10 per cent. 

group as 6 per cent. 

Joslin's Resume of Allen's Treatment — Fasting. — Fast un- 
til sugar-free. Drink water freely and one cup of tea and 
one cup of coffee if desired. If sugar persists after two days 
of fasting, add in divided portions 300 c.c. clear meat broth. 

Alcohol. — If acidosis (diacetic acid) is present, give 0.5 c.c. 
of alcohol per kilogram body weight daily until acidosis 
disappears. Alcohol is best given in small doses every three 
hours. 

Carbohydrate Tolerance. — When the twenty-four-hour urine 
is sugar- free, add 150 grams of 5 per cent, vegetables, and 
continue to add 5 grams carbohydrate daily up to 20 grams, 
and then 5 grams every other day, passing successively up- 
ward through the 5, 10 and 15 per cent, vegetables, 5 and 10 
per cent, fruits, potato and oatmeal to bread, unless sugar 
appears or the tolerance reaches 3 grams carbohydrate per 
kilogram body weight. 

Protein Tolerance. — When the urine has been sugar-free 
for two days, add 20 grams protein (three eggs) and there- 
after 15 grams protein daily in the form of meat until the 
patient is receiving 1 gram protein per kilogram body weight 
or if the carbohydrate tolerance is zero, only % gram per 
kilogram body weight. Later, if desired, the protein may 
be raise to 1.5 gram per kilogram body weight. 

Fat Tolerance. — While testing the protein tolerance, a 
small quantity of fat is included in the eggs and meat given. 
Add no more fat until the protein reaches 1 gram per kilo- 
gram body weight (unless the protein tolerance is below this 
figure), but then add 25 grams fat daily until the patient 



484 DISTURBANCES OF NORMAL METABOLISM 

ceases to lose weight or receives not over 40 calories per kilo- 
gram body weight. 

Reappearance of Sugar. — The return of sugar demands 
fasting for twenty-four hours or until sugar-free. The diet 
preceding the reappearance of sugar is then resumed except 
that the carbohydrate should not exceed half the former 
tolerance until the urine has been sugar- free for two weeks, 
and it should not then be increased more than 5 grams per 
week. 

Weekly Fast Days. — Whenever the tolerance is less than 
20 grams carbohydrate, fasting should be practised one day 
in seven; when the tolerance is between 20 and 50 grams 
carbohydrate, 5 per cent, vegetables and one-half the usual 
quantity of protein and fat are allowed upon the fast day; 
when the tolerance is between 50 and 100 grams carbohydrate 
the 10 per cent, and 15 per cent, vegetables are added as 
well. If the tolerance is more than 100 grams carbohydrate, 
upon the weekly fast day the carbohydrate should be halved. 

Bread is seldom prescribed, because it is so easy for a 
patient to overstep the limits. Many patients use bread 
substitutes, such as Huntley and Palmer's Akoll Biscuits, 
Barker's Gluten Flour 1 (Brand A), Hepco Flour, 2 Lyster 
Bros. Diabetic Flour, Whitefield, New Hampshire. The 
quantity of fat which it is necessary to give a severe case is 
considerable. A diabetic weighing 60 kilograms requires 
at least 30 calories per kilogram body weight to be up and 
about the hospital, with an occasional walk. Since in the 
severe cases not more than 10 grams carbohydrate, represent- 
ing 40 calories, can be given in this form, and seldom more 
than 75 grams protein (1.25 grams per kilogram body weight) 
which would amount to 300 calories more, the balance of 
the diet must be made up of 150 grams fat, amounting to 
1350 calories, and even more unless 15 grams alcohol are 
given, which would amount to 105 calories. 

Quantity of Food Required by a Severe Diabetic 
Patient Weighing 60 Kilograms. 

Quantity, 
Food grams. 

Carbohydrate .... 10 

Protein ...... 75 

Fat 150 

Alcohol 15 

Total .... 1795 



1 Herman Barker, 433 Broadway, Somerville, Mass. 

2 Waukesha Health Products Co., Waukesha, Wisconsin. 



Calories, 


Total 


per gram. 


Calories 


4 


40 


'4 


300 


9 


I350 


7 


I05 



DIABETES MELLITUS 485 

Should the patient remain sugar-free and the weight be 
maintained upon this diet, gradually the quantity of fat 
could be lowered and the carbohydrate increased. A very 
few of the patients have a tolerance for between 200 and 300 
grams of carbohydrate. With most the tolerance is below 
100 grams, and with the majority it is under 50 grams. 

The patient should have one day of restricted diet each 
week, no matter how mild the case. This is done partly to 
spare the function which controls the carbohydrate metabo- 
lism, but also to remind the patient of what a strict diet 
really is. The patient is told to gain little or no weight, 
and as Allen advises, not to come up to his former weight. 
The severer cases examine the urine daily, and the milder 
ones once a week. The patients are instructed to lead less 
strenuous lives. Unfortunately, they feel so well that often 
this advice is disregarded, and he believes that all of us err 
in allowing our patients to do too much. They should have 
nine hours in bed at night and should have a quiet hour of 
rest each day, no matter how well they feel. 

Diabetic Special Receipts. — The curtailment of the carbo- 
hydrates in diabetes is the most difficult problem to deal with 
and it is usually upon this rock that patients wreck their 
treatment unless they are exceptionally determined. With 
the newer method of giving the carbohydrate largely in the 
form of the 5, 10, 15 and 20 per cent, vegetables there is 
introduced a considerable food bulk which is satisfying and 
makes the loss of concentrated carbohydrate foods such as 
bread, cereal, etc., less disturbing. But there is in addition 
the necessity of supplying a variety in the diet and the cry 
for bread substitutes is more or less universal. 

The following bread substitutes and "near" carbohydrate 
recipes are given to assist those who must make up the diabe- 
tic's menus. 

Akoll Biscuit (Hiintly and Palmer). — Carbohydrate, 2.7 
per cent. ; nitrogen, 7 per cent. Each biscuit weighs 5.1 gm. 
and contains 0.14 gm. carbohydrate and 0.41 gm. nitrogen. 

Soja-bean Meal Biscuit, made from soja-bean meal, to be 
procured from Thos. Metcalf Co., Boston, Mass. Sugar, 
9.34 per cent.; starch, none; protein, 44 to 64 per cent. ; fat, 
19.43 P er cent. 

Gluten-meal Biscuit, made of Barker's Gluten Food A, pro- 
cured from H. B. Barker, Somerville, Mass. Carbohydrate 
about 4 per cent.; nitrogen, 13 per cent. 

Gluten Biscuit and potato-gluten biscuit procured from 
Battle Creek Sanitarium Food Co. Carbohydrate, 10 per 
cent.; nitrogen, 12 per cent. 






486 DISTURBANCES OF NORMAL METABOLISM 

Casoid Biscuit, procured from Thos. Leeming and Co. r 
New York City. Carbohydrate, o to 2 per cent.; nitrogen, 
10 per cent. 

Proto Puff No. 1, procured from Health Food Co., Lexing- 
ton Avenue, New York City. Carbohydrate, 10 per cent.; 
nitrogen, 12 per cent. 

Diabetic Milk {Wright). — Take a definite quantity of milk 
and dilute with three or four volumes of distilled water to 
which glacial acetic acid has been added, e. g., 6 to 12 c.c. 
(i}4 to 3 drams) to 500 c.c (1 pint) of water. This precipi- 
tates the casein and fats. 

Allow it to settle and strain through cheesecloth, wash 
repeatedly. Redissolve the curd in a 1 per cent, solution of 
the following mixture, sufficient to make the original amount 
ofjnilk used. 

Potassium chloride 9-9 

Sodium chloride 11.5 

Monopotassium phosphate 13.8 

Dipotassium phosphate 10. o 

Citrate of potassium 5.9 

Dimagnesium phosphate 4.0 

Magnesium citrate 4.4 

Dicalcium phosphate 8.0 

Tricalcium phosphate 9.6 

Calcium citrate . .' 25.5 

Calcium oxide 5.5 

Sodium carbonate : 4° • ° 

Analysis of Wright's Diabetic Milk (Granat) 

Specific gravity ion 

Carbohydrate , " . 0.015 per cent. 

Protein i-9<>7 

Fat 3- 600 

Ash 0.200 

Total solids 5-722 

Sodium chloride . . . o.no 

Special Recipes for the Use of Oatmeal. — (On oatmeal days 
the oatmeal porridge may be varied with these.) 

Oatmeal Griddle Cakes. — Into the beaten white of one egg 
stir 100 gm. (33/3 oz.) of cooked oatmeal and 5 gm. (Ye oz.) 
(full teaspoonful) of melted butter. Cook on hot griddle. 
Eat with butter and cinnamon. 

Oatmeal Popovers. — Into the white of one egg, beaten up, 
stir 100 gm. (33^ oz.) of cooked oatmeal. Mix well. Bake 
for twenty minutes in hot popover pan. Serve with butter. 

Oatmeal Muffins. — Finely ground oatmeal 130 gm. (2 half- 
pint cups). Add one heaping teaspoonful of baking powder 
and one-half teaspoonful of salt. Mix well, and add \\i 
cups of cold water and add melted butter or lard 30 gm. (1 



DIABETES MELLITUS 487 

oz.). Beat well and bake in a very hot oven in buttered 
muffin pans. 

Soja-bean Meal Biscuits. — i cup cream, 2 eggs, 1 teaspoon - 
ful baking powder, salt q. s. Use enough soja-bean meal to 
make a batter, not very thick. Make into eight cakes and 
bake. 

Soja-bean Pancake. — Sift one tablespoonful of soja-bean 
flour with a little salt, add water until a thin batter is made, 
then beat in thoroughly the yolk of an egg, then mix in the 
beaten white of an egg. Cook brown on a hot griddle. 

Baked Custard.— 3 tablespoonfuls of cream; 1 egg] 5 table- 
spoonfuls of water; 2 or 3 saccharin tablets (or less) to taste; 
10 drops of vanilla essence. Beat well; bake in buttered 
dish for twenty minutes; grate a little nutmeg on top. 

Ice-cream. — 3 tablespoonfuls of water; 3 tablespoonfuls of 
cream ; 2 tablespoonfuls of coffee with 2 or 3 saccharin tablets 
dissolved in it; 1 egg. Mix in sauce pan and beat until 
thick. Cool and freeze. 

Cranberries, stewed and sweetened with saccharin to taste. 

These special recipes are 'argely adapted from Janeway's 
Treatment of Diabetes, in Musser and Kelly's Therapeutics. 

Bran Biscuits (Rockefeller Institute Recipe . — Bran, 60 gm.; 
salt, one-fourth teaspoonful; agar-agar (powdered), 6 gm.; 
cold water, 100 c.c. (yi glass). 

Tie the bran in cheesecloth and wash under cold water tap 
until water is clear. Mix agar in the water cold 100 c.c. (y£ 
glass) and bring to the point of boiling. Add to washed bran 
the salt and agar- agar solution. Bake in a moderate oven 
from forty-five to fifty minutes. 

Lyster Brothers 1 put up a Prepared Casein Diabetic Flour 
for gems, muffins, etc., which is said to be practically starch- 
free. 

Carbohydrate Content of Foods Commonly Used in Diabetic Diets. 
Under 5 Per Cent. Carbohydrates. 2 

Per cent. Per cent. 

Casoid Baking Powder ... o Soson I . I 

Dr. Bouma Sugar-free Fat-milk o Rose's Diabetesmilch . . . 1.2 

Van i\bbott's Diabetic Table Casoid Sugarless Marmalade . 1.2 

Jelly, Orange o Energin 1.3 

AYhiting's Sugar-free Milk . . Casoid Sugarless Jam . . . 1.5 

Rademann's Johannisbeer Saft Kalari Biscuit 1.7 

ohne Zucker 0.9 Casoid Dinner Rolls . . . 2.1 

Kalari Batons ('09) . . . . 0.9 Casoid Flour 2.2 

Glidine 1 . o Tropon 2.7 

Roborat 2.9 Barker's Gluten Food "A" . 4.1 

Gericke's Aleuronat . . . . 3.1 Bauer's Sanatogen . . . . 4.2 

1 Lyster Brothers, 105 Barnard Street, Andover, Mass. 

2 J. P. Street: Eighteenth Report of Food Products, 1913, Conn. Agri. Ex- 
periment Station. 



488 DISTURB A NCES OF NORMA L ME TABOLISM 



Jireh Diatetic Pine Nuts . 
Rademann's Preserved Fruits, 

"entzuckert" 

Kellogg's Protose .... 
Hundhausen's Aleuronat (pure) 



Per Cent. Per Cent. 

3.4 Kellogg's Pine Nuts . . . 4.2 
Kellogg's 80 per cent. Gluten 

3 . 5 Biscuits 4.4 

3.6 Amthor's Weizen-Protein . . 4.8 
4.0 Bischof's Gluten Flour . . 5.0 



5 to 10 Per Cent. Carbohydrates. 



Casoid Biscuits No. 2 . . . 
Rademann's Preserved Fruits 

"in eigenem Saft" 
Casoid Biscuits No. 1 ('13) 
Barker's Gluten Food "B" 
Kellogg's Nuttolene 
Nashville Nutcysa . 
Huntley and Palmer's Akoll 

Biscuits 

Nashville Nutfoda . 
Rademann's Preserved Fruits 

"ohne Zucker" 
Muller's Tomatoes fur Dia 

betiker 

Kalari Batons ('13) . 



Per cent. 

5-6 



Per 



Barker's Gluten Food "C" 
Casoid Biscuits No. 3 . 
Gumpert's Ultrabrot . 
Kellogg's 80 per cent. Gluten 

('12) 

Van Abbott's Almond Flour 
Casoid Biscuits No. 1 ('06, '09) 
Kellogg's Almond Butter . 
Fromm's Uni Bread 

Plasmon 

Gumpert's Ultramehl . 
Metcalf's Vegetable Gluten 

l'i3) ...... 

Groetzsh's Pfeffernusse . 



cent. 

7-7 
7" 



10 to 15 Per Cent. Carbohydrates. 



Per cent. 
Kellogg's Pure Gluten Biscuit 

('06) 10.2 

Hundhausen's Aleuronat (less 

pure) 10.6 

Gumpert's Diabetiker-Stangen 1 1 . o 
Health Food; Pure Washed 

Gluten Flour ('13) . . . 1 1. 1 
Health Food; Alpha Diabetic 

Wafers 1 1 . 3 

Loeb's Imported Gluten Flour 11. 8 
Health Food No. 1 ; Proto Puffs 1 1 . 9 
Kellogg's Potato Gluten Bis- 
cuit ('06, '09) 11 .9 

Kellogg's Nut Meal . . . 12. 1 

Van Abbott's Walnut Biscuits 12.3 

15 to 20 Per Cent. 

Per cent. 

Fritz's Litonbrot . . . . 15.4 

Van Abbott's Caraway Biscuits 15.9 

Van Abbott's Diabetic Rusks . 16.0 

Casoid Chocolate Almonds . 16. 1 

California Paper Shell Almonds 16.3 

Callard's Cocoanut Biscuit . 16.4 

Van Abbott's Ginger Biscuits . 16.7 
Rademann's Diabetiker-Choko- 

lade 16.9 

Health Food Almond Meal . 16.9 

20 to 25 Per Cent. 

Per cent. 

Goldscheider's Sinamylbrot . 20.2 

Callard's Almond Shortbreads 20.7 

Callard's Casoid Rusks . . 20.8 



12.6 
12.5 



Per cent 
Kellogg's 80 per cent. Gluten 

(•09) 

Van Abbott's Gluten Flour . 
Van Abbott's Gluten Butter 

Biscuits 12.7 

Nashville Nut Butter . . . 13.0 
Van Abbott's Euthenia Bis- 
cuits 13.2 

Kellogg's Nut Butter . . . 13.9 
Bischof's Diabetic Gluten 

Bread 14.3 

Fromm's Litonbrot . . . 14.3 
Gericke's Sifarbrot . . . . 15.0 
Jireh Diabetic Baking Powder 15.0 
Peanut Butter (range 12-20) . 15.0 

Carbohydrates. 



Per cent. 
Groetzsch's Esschokolade . . 17.2 
Hundhausen's Aleuronatzwie- 

back . . 
Callard's Ginger Biscuit 
Callard's Prolactic Biscuit 
Rademann's Erdnuss-Brot 
Fritz's Braunes Luftbrot ' 



Groetzsch 's 
brezeln 



B" 

Diabetiker-Salz- 



20.0 



Carbohydrates. 

Per cent. 
Rademann's Litonbrot . . 21.6 
Rademann's Diabetiker-Choko- 

lade-Biskuit 21.9, 



DIABETES MELLITUS 



489 



Per Cent. 
Rademann's Diabetiker-Makro- 

nen 20.8 

Plasmon Cocoa 20.9 

Health Food Protosoy Diabetic 

Wafers 21.2 

Jireh Patent Cotton Seed Flour 21 .3 

Casoid Lunch Biscuit . . . 21.6 



Per Cent. 

Fritz's Mandelbrot . . . 23 . 1 

Cereo Soy Bean Gruel Flour . 23 . 7 

Health Food Salvia Sticks . 24.0 
Health Food Protosoy Soy 

Flour 24.5 

Metcalf's Soja Bean Meal . 25.0 



25 to 35 Per. Cent. Carbohydrates. 



Fromnrs Luft Bread . 

Van Abbott's Gluten Bread . 

Spencer's Almond Paste 

Van Abbott's Midolia Biscuits 

Van Abbott's Gluten Semola . 

Fromm's Conglutin-Diabetiker- 

Schokolade 

Frank's Protein-Roggenbrot . 
Van Abbott's Gluten Biscottes 
Health Food No. 2 ; Proto Puffs 
Frank's Protein-Weizenbrot . 
Ferguson Gluten Bread 
Gum Gluten Breakfast Food 
Gericke's Sifarbiskuits 



Per cent. 

7 
9 
6 
6 
4 



Per cent. 

Jireh Soja Bean Meal . . . 25.8 

Gericke's Dreifach-Porterbrot . 26.0 

Groetzsch's Kochschokolade . 26.1 
Brusson Chocolate with Added 

Gluten 26.4 

Rademann's Diabetiker-Stangen 27.0 
Rademann's Diabetiker-Dessert- 

Geback ... . . 27.5 

Nashville Malted Nut Food . 27.5 
Gumpert's Doppel-Diabetiker- 

Zwieback 27.6 

Metcalf's Vegetable Gluten 

('06) 28.1 

Health Food Pure Washed 

Gluten Flour ('06) . . . 29.5 

Diet for Diabetics with Gout. — When gout accompanies or 
complicates diabetes the necessity for regulating the diet in 
conformity with the necessities of both diseases is evident. 
When a case of diabetes with very low carbohydrate toler- 
ance has a fairly good protein tolerance, and one naturally 
comes to rely on the latter for furnishing a fair number of 
calories, in the presence of gout, care must be exercised with 
regard to the sort of protein that is ordered. If the case 
shows very mild evidences of gout it may only be necessary 
to curtail an excess of purine bodies by entirely eliminating 
stock soups and giving only meats with the lowest purine 
content, such as fish and chicken, either but once a day or 
once every other day. When the case is more pronounced 
it is necessary to eliminate the purines from the diet as much 
as possible, using the animal albumins which are purine-free, 
such as egg albumen and cheese principally and the vege- 
table proteins contained in beans, peas and lentils. In this 
way we can secure the required amount of albumin which 
is purine-free or nearly so, in conformation with the require- 
ments of gout. 

Exerting care in the selection of foods it is thus possible to 
construct a diet which is suitable for both diabetes and gout. 

Diabetes in Elderly People or in the Young. — In many 
text-books these extremes of life are treated dietetically 
somewhat differently from the ordinary average adult. In 
elderly people it is often felt that a small amount of sugar 



490 DISTURB A NCES OF NORMAL METABOLISM 

(below 2 per cent.) is no particular menace and therefore 
need not be treated very rigorously particularly if the subjects 
are obese. As a matter of fact every case of glycosuria has 
potentialities of disaster and if untreated tends to grow progres- 
sively , although often very slowly, worse ; on this account they 
should all be made and kept sugar- and acid-free (ketonuria). 
In the mild cases this is usually a simple matter, in the more 
severe they should be treated more vigorously and not 
treated lightly as of little importance as is so often done. 
One great reason for this care being the fact that such elderly 
people with even a mild diabetes are prone to intercurrent 
infections, gangrene, etc., all of which are rendered much 
less probable if the hyperglycemia can be reduced to normal. 

In diabetes in the very young there is the necessity for the 
most painstaking care, as these cases tend to grow progres- 
sively worse, most of them ending fatally. 

Allen's treatment offers the best plan of attack and some 
really remarkable cases are on record in which this treatment 
has at least put off indefinitely the fatal acidosis. While 
it is not such a difficult matter to render them sugar- and 
acid-free, it is usually extremely difficult to get them up to a 
fair maintenance diet and almost impossible to keep them 
nourished in accordance with the demands of the growing 
organism: It should be nevertheless tried and every effort 
made to prolong life with the hope that the disturbed func- 
tion may again be reestablished. 

Diet for Obesity with Diabetes. — As in the case with gout 
associated with diabetes we must find certain means by diet 
for controlling the obesity factor in this case. 

In mild cases regulating the diet on the caloric basis by 
giving a diet one-fourth to one-third lower in calories than 
would be ordinarily required by a person of the same height 
we can without difficulty reduce the patient; all foods that 
are allowable so far as the diabetes is concerned may be used 
but in reduced amount. In the more severe cases of dia- 
betes there is usually no difficulty in reducing patients, for 
with Allen's method of treatment fasting is the means by 
which the glycosuria and ketonuria are cleared up, and the 
patients readily lose about one pound a day or thereabout. 
When feedings are again begun the patients continue to lose 
weight, since for a considerable time, while testing out the 
protein, fat and carbohydrate tolerance, they are on an 
insufficient diet. The dietary regulation of this complica- 
tion of diabetes must receive especial attention in that it is 
recognized that a too rapid withdrawal of carbohydrates 
often hastens an impending acidosis. These patients should 



OBESITY 491 

never be jumped from ordinary diet to fasting diet but the 
reduction must be made gradually extending over several 
days watching the ketonurea as a guide to the rapidity of 
carbohydrate reduction. 

As has already been pointed out this loss of weight is a 
distinct advantage and care must be exercised not to allow 
it to increase to the former proportions. 

Diet in Diabetes Complicated by Nephritis. — It is unfor- 
tunately true that many cases of diabetes are complicated 
by nephritis, particularly among older people. This always 
adds a difficult factor to the situation and in choosing a suit- 
able diet for such cases it must be first determined which 
disease is of chief importance. If for example the nephritis 
presents the picture of an acute disease, the diet must con- 
form to that useful in such a condition (more or less regard- 
less of the diabetes, although of course, one would naturally 
omit from the diet all food which is primarily carbohydrate) . 
In this condition one should rely upon an exclusively milk 
diet for a time, later adding egg albumen and fats in the 
form of cream and butter and as the patient showed an im- 
provement in the renal condition, an attempt may be made 
to increase the diet along the lines best suited to diabetics. 
Of course a day or two of starvation at the outset would be 
good for the diabetics and would rest the kidneys, as well, 
water alone being given or the so-called "fasting" diet, 
(p. 477), but a return to milk diet would probably cause a 
reappearance of the glycosuria unless the case were very 
mild. 

If the nephritis is a chronic affair of some time standing, 
one must treat primarily the diabetes, taking care in planning 
the diet that the protein ration shall be kept as low as pos- 
sible to maintain nitrogenous equilibrium and that no pur- 
ine containing protein shall be used or at most only those 
animal proteins that contain the lowest percentage of purine 
bodies (see Purine Bodies). In such cases it is well to place 
as much reliance on the fats as the metabolism will stand 
with the hope that the carbohydrate tolerance may be in- 
creased rapidly. At best it is often a nice point to select a 
diet which is suitable to both conditions, but with care it can 
usually be done unless the diabetes is of the most severe 
variety. 

OBESITY. 

In America there are fewer cures for obesity undertaken 
than abroad, for, probably partly on account of national 
characteristics, partly on account of the climate and partly 



492 DISTURBANCES OF NORMAL METABOLISM 

because our leisure class is not so large as one formerly found 
abroad, there are fewer obese people here. Whatever the 
causes fewer people take up seriously the matter of reduc- 
tion of weight than one finds on the other side of the water. 

The Causes of Obesity. — The causes of obesity may be 
divided into: first, lack of exercise. Second, overfeeding. 
Third, hereditary constitutional causes. 

For certain reasons, not thoroughly understood, the ten- 
dency to obesity may not, and in fact usually does not, show 
itself until toward middle life, at which time all three factors 
seem to be the most active in its production. There are, of 
course, numerous cases of obese youngsters of both sexes, 
usually from constitutional causes, such as hypopituitarism 
in which there is an increased tolerance for carbohydrates, but 
these are the exception and do not fall into the class of cases 
that apply for relief of their obesity per se. 

Most persons in adult life attain to the use of what von 
Noorden calls their " maintenance diet," i. e., their regular 
dietary which suffices, without effort on their part, to keep 
them at an average, even weight If these people reduce 
their activities without reducing the total quantity of food, 
the result will be an increase in weight, which if ^maintained 
long enough will result in obesity. Or these same people on 
their maintenance diet may entirely change their mode of 
life and under ore mattractive surroundings unconsciously 
eat more with the same result, so far as increase in weight 
goes. 

There are always exceptions to these conditions and one 
often sees a spare individual who eats much more than would 
suffice to fatten him, but who does not get fat. So, too, some 
obese persons are comparatively small eaters and in old age 
with metabolism at ''slow speed" weight is maintained often 
on very little food. 

So far as the constitutional causes go, hypopituitarism has 
already been spoken of. Hypothyroidism is a fairly fre- 
quent cause for increase of weight and may develop at any 
time, but usually at middle life or in women at the climac- 
teric, for in men diminished thyroid secretion is an extremely 
rare cause for obesity. 

What it is that makes an obese parent- pass his or her fat 
characteristics to the children is still a mystery. 

Given a case of increased fat deposition, what must be our 
criteria for saying whether such an individual should under- 
take a reduction cure or not, as many may think that they 
are overweight and yet when judged by the average, are 
found to be within normal limits? The method most in. 



OBESITY 



493 



vogue is to judge the normal by the relation of height to 
weight, for which numerous tables have been prepared. In 
America the tables prepared by one of the life insurance 
companies are much in use; or abroad, Tibbie's table an- 
swers the same purpose. 



Average Weights for Men and Women, as Compiled by the Metro- 
politan Life Insurance Company. 

Men. 





Height, 


Weight, 


Ft. 


In. 


Lbs. 


5 


1 


120 


5 


2 


125 


5 


3 


I30 


5 


4 


135 


5 


5 


141 


5 


6 


145 


5 


7 


I50 


5 


8 


154 


5 


9 


159 


5 


10 


164 


5 


ii 


I69 


6 




175 


6 


i 


I8l 


6 


2 


188 





Women. 




Height 




Weight, 


Ft. 


In. 


Lbs. 


4 


10 


108 


4 


II 


112 


5 




114 


5 


I 


118 


5 


2 


123 


5 


3 


126 


5 


4 


129 


5 


5 


133 


5 


6 


137 


5 


7 


142 


5 


8 


I46 


5 


9 


150 


5 


10 


154 


5 


11 


158 



Height. 



Normal Weight of Males at Various Ages. 

Ages. 







15 to 24 


25 to 29 


30 to 34 


35 to 39 


40 to 44 


45 to 49 


50 to 54 


55 to 






years. 


years. 


vears. 


years. 


years. 


years. 


years. 


years, 


Ft. 


In. 


Lbs. 


Lbs. 


"Lbs. 


Lbs. 


Lbs. 


Lbs. 


Lbs. 


Lbs. 


5 


O 


120 


125 


128 


131 


133 


134 


134 


134 


5 


1 


122 


126 


129 


131 


134 


136 


136 


136 


5 


2 


124 


128 


131 


133 


136 


138 


138 


138 


5 


3 


127 


131 


134 


136 


138 


141 


141 


141 


5 


4 


131 


135 


138 


140 


143 


144 


145 


145 


5 


5 


134 


' 138 


141 


143 


I46 


147 


149 


149 


5 


6 


138 


142 


145 


147 


150 


151 


153 


153 


5 


7 


142 


147 


150 


1.52 


155 


156 


158 


158 


5 


8 


I46 


151 


154 


157 


160 


I6l 


163 


163 


5 


9 


I50 


155 


159 


162 


165 


166 


167 


168 


5 


10 


154 


159 


164 


167 


170 


171 


172 


173 


5 


11 


159 


164 


169 


173 


175 


177 


177 


178 


6 




165 


170 


175 


179 


180 


183 


182 


183 


6 


1 


I70 


177 


I8l 


185 


186 


189 


188 


189 


6 


2 


176 


184 


188 


192 


194 


196 


194 


194 


6 


3 


I8l 


190 


195 


200 


203 


204 


201 


198 



Having this standard before us we can decide quickly 
whether a given individual is overweight or not, so far as can 
be said for a healthy man or woman, although conditions of 
disease may indicate the necessity for a reduction of weight 
below that which is normal in health. 
The Conditions for which an Obesity Cure is Indicated are : 
1 . Those people whose weight is excessive for their height. 

1 Tibbies: Food in Health and Disease, p. 465. 



494 DISTURBANCES OF NORMAL METABOLISM 

2. Those who although within the normal limits but who 
on account of some disability or occupation would be better 
off with less weight. 

3. Those who have serious circulatory diseases are almost 
invariably improved if relieved of excessive weight. This 
refers especially to cardiovascular renal diseases. 

4. Those who have a fairly high grade of chronic emphy- 
sema or bronchitis. 

Of those who fall in the first class, there is little more to be 
said, if the excess of weight is considerably above the aver- 
age, they would be better for having less. 

Those in the second class may be those with some disabil- 
ity of their locomotive apparatus or who, on account of their 
occupation, must remain a little underweight, e, g., dancers,, 
acrobats, etc. 

Of those in class three, more needs to be said. There is 
every reason to feel, and from clinical experience to know, 
that cases of chronic renal or cardiovascular disease, whether 
valvular or muscular, are much better off if their excessive 
weight is removed and are brought even below their normal 
weight for their height. The results in this direction are 
often brilliant and it should be insisted upon in all such cases 
that an earnest attempt be made to reduce the weight. The 
results are seen in a lessened tendency to dyspnea, edema 
and palpitation, all present in cases of circulatory disease- 
complicated by obesity and to a less extent even in cases 
with normal circulatory apparatus, but accompanied by 
obesity. 

In cases of hypertension the results are often even more- 
brilliant and if we can reduce these patients we almost al- 
ways reduce the blood-pressure to a greater or less extent 
and often very markedly. The most convincing statistics- 
on this are published by Gaertner, showing the relation of 
the decline in blood-pressure to the decrease in weight (p. 495). 

There is one class of cases in whom the question comes up 
as to whether or not they should be subjected to a reduction 
cure, namely old people who are more or less obese. The 
general concensus of opinion for these people is that they 
should not undergo a marked reduction unless they have 
serious cardiac, circulatory, renal or pulmonary complica- 
tions, for if otherwise healthy they will naturally tend to 
grow thinner as they approach extreme old age, at least this 
seems to be the rule and they bear reduction cures rather 
badly. 

The Objects of a Reduction Cure are: 

1. To effect a slow consumption of the previous fat de- 
posits. 



OBESITY 495 









Weight, 


Height, 


Blood-pressure 


No. 


Sex. 


Age. 


Kg. 


Cm. 


mm. Hg. 


I 


F. 


32 


114 


I6l 


I65-II5 


2 


F. 


31 


82 


164 


115- 90 


3 


M. 


49 


103 


170 


200-155 


4 


F. 


16 


77 


167 


165-130 


5 


M. 


67 


90 


168 


165-120 


6 


F. 


37 


82 


157 


105- 95 


7 


M. 


34 


105 


174 


100- 90 


8 


F. 


5i 


9i 


153 


120-100 


9 


M. 


40 


88 


177 


no- 95 


IO 


M. 


3i 


102 


I6 9 


120-100 


ii 


F. 


33 


117 


162 


130-100 


12 


F. 


52 


79 


163 


140-100 


13 


F. 


28 


90 


164 


no- 90 


14 


F. 


26 


106 


176 


1 16-100 


15 


M. 


44 


96 


176 


150-108 


16 


F. 


40 


84 


166 


130-100 


17 


M. 


53 


87 


175 


140-11* 


18 


F. 


42 


103 


155 


145-100 


20 


F. 


55 


74 


157 


140- 95 


21 


F. 


52 


80 


I6l 


I35-II5 


22 


M. 


66 


114 


170 


145-118 


23 


M. 


44 


81 


174 


150-120 


24 


F. 


22 


115 


170 


130-115 


25 


F. 


38 


72 


159 


180-110 


26 


F. 


42 


93 


167 


140-128 


27 


M. 


39 


105 


I8l 


115-110 


28 


F. 


23 


92 


157 


no- 95 



2. The maintenance of the normal metabolic processes. 1 
There are two types of obese persons: 

1. Plethoric type, occurring in healthy, often athletic per- 
sons, with an exaggerated normal appetite. After forty 
they are apt to develop serious organic trouble. They often 
show increased blood-pressure. 

2. Anemic type, occurring for the most part in women who 
are flabby and anemic and who suffer from all sorts of disor- 
ders but who are less to develop serious troubles than the 
plethoric individuals. 2 

Having decided upon a reduction cure in any patient, what 
are the steps and methods by which this may be best accom- 
plished? It is here that we meet with a bewildering array of 
methods for the reduction of obesity, probably any one of 
which will result in the object sought, some methods being 
more applicable to one temperament or set of conditions, 
another to a different kind, and the cases must be individual- 
ized to some extent, even in the use of any one method. 

In the lesser degrees of obesity where only slight, or at 
most, very moderate reduction is sought, it is usually enough 
to regulate the patient's diet by cutting out certain classes of 
foods, e. g., sugars, much starchy or fat foods, and increasing 

1 Anders: New York Med. Jour., 1914, c. 1. 

2 Saundley: Med. Press and Circul., 1914, X.S., xcviii, 112. 



496 DISTURBANCES OF NORMAL METABOLISM 

the bodily exercise ; but where anything like a severe reduc- 
tion cure is indicated, it is often necessary to weigh all the 
food as otherwise the error is too great and our efforts are 
not successful, the method and the physician both coming in 
for the blame. 

In the treatment of the plethoric type of obesity we can 
use more stringent methods as to diet and more vigorous 
exercises. In the anemic type the reduction must be made 
possibly more slowly and carefully with attention fixed on 
the upbuilding of the patient's blood and general condition, 
as well as on the details of the reduction. 

Reduction Cures. — Von Noorden Cure. — Among all the 
methods to be found none appeals more strongly to the in- 
telligence than the reduction cure recommended by von 
Noorden, as it places the emphasis on the regulation of food 
intake as affecting: first, slight obesity; second, moderate 
obesity and third, marked obesity. 

The assumption is made that a patient weighing 70 kilos 
(154 pounds) requires for ordinary activities 37 calories per 
kilo or 2590 calories in all as his "maintenance" diet; if this 
patient weighs 100 kg. (220 lbs.) this is 30 kg. over what he 
should weigh for his height, and while the 2590 calories are 
enough to maintain him at 70 kg. (154 lbs.) it would require 
1 1 10 extra calories to feed these 30 kg. extra. The ideal 
weight for his height being 70 kg., his maintenance diet is 
therefore 2590 calories, so that in calculating the calories 
necessary for any individual, account must be taken of the 
maintenance diet for that particular person from which must 
be taken one-fifth, two-fifths, or three-fifths of the main- 
tenance allowance, e. g., 

1st. Degree of reduction diet four-fifths of the demand, 
2000 calories. 

2d. Degree of reduction diet, three-fifths of the demand, 
1500 calories. 

3d. Degree of reduction diet, three-fifths to two-fifths of 
the demand, 1500 calories down to iooo. 1 

It is easy to arrange Diets I and II, for all that is needed in' 
Diet I is to omit all visible fat, such as oil, butter, fat meat, 
etc., to have vegetable and farinaceous dishes made with 
little fat and to prohibit the use of alcohol. 

In Diet II dishes made from flour, stewed fruits, milk and 
soups containing flour must be forbidden as well. The results 
of these diets are slow, but if lived up to, the reduction will 
come gradually. 

In Diet III, the foods should be chosen from this list: 

1 Disorders of Metabolism and Nutrition, von Noorden, Obesity, p. 31. 



OBESITY . 497 

" Coffee, tea without milk or sugar; meat broth (fat 
skimmed off) with vegetables ; lean meat or fish (total weight 
250 to 350 gm. (8 to 12 oz.) weighed cooked); lean cheese; 
abundant green vegetables and salads, prepared with as 
little fat or oil as possible; vinegar, lemon, pickles, tomatoes, 
celery, radishes (abundant raw fruit with small percentage 
of sugar, as apples, peaches, strawberries, raspberries, cur- 
rants, blueberries, sour cherries, grapefruit, early oranges, 
etc.) ; coarse bread (bran or graham bread) in quantities of 
from 40 to 70 gm. (1 J^ to 2% oz.) per day only; potatoes 
prepared without fat, in quantities of from 80 to 150 gm. 
(2% to 5 oz.), mineral waters ad libitum; wine in weak per- 
sons up to 200 ex., but preferably omitted altogether; eggs, 
one or two; skimmed milk; buttermilk." 1 

The diet must be calculated in calories necessary for the 
individual, and von Noorden advises against this third de- 
gree of reduction except under direct supervision of the 
physician, best in a sanatorium. 

Fat and Carbohydrate Restriction. — The fats .must be 
restricted to 30 gm. (1 oz.) per day, but considerable carbo- 
hydrate in fruit, potatoes, bread and buttermilk are allowed. 
Von Noorden says that it is not necessary to go below 100 
gm. (3}/£ oz.) of carbohydrate in a day's ration and he 
usually permits 120 gm. (4 oz.). This fairly generous supply 
of carbohydrate contributes to sparing of the body albumin 
better than 53 gm. of fat, although the latter has the same 
caloric value. 

Hunger should not be allowed, for it will result in the fail- 
ure of the cure or else a rapid return to overeating as soon as 
the cure is over. This may be accomplished by feeding 
foods of considerable bulk but of low food value. 

Protein Allowance. — The diet allows a fair amount of pro- 
tein, 120 to 180 gm. (4 to 6 oz.) which is necessary to spare the 
body albumin. On the basis of what has been said von 
Noorden builds his minimal and maxinal diets as follows: 

Minimal. Maximal. 

Protein .... 120 gm. (4 oz.) 492 cal. 180 gm. (6 oz.) 738 cal. 

Fat 30 gm. (1 oz.) 280 cal. 30 gm. (1 oz.) 280 cal. 

•Carbohydrate . . 100 gm. (3^ oz.) 410 cal. 120 gm. (4 oz.) 492 cal. 

1182 cal. 1510 cal. 

A sample of the von Noorden Diet: 2 

Breakfast: Lean meat, 80 gm. (2% oz.) ; bread, 25 gm. 
(1 oz.); tea, one cup with milk, no sugar. 

1 Von Noorden, ibid. 

2 Osier's Practice. 
32 



498 DISTURBANCES OF NORMAL METABOLISM 

Midforenoon: One egg. 

Luncheon: Soup, i small portion; lean meat, 160 gms. 

(53^ oz.); potatoes, 100 gms. (3^ oz.); fruit, 100 

gms. (33^ oz.). 
Afternoon: 

3 p.m. Cup of black coffee. 

4 p.m. Fruit, 200 gm. (6% oz.). 
6 p.m. Milk, 250 c.c. (8 oz.). 

Dinner: Meat, 125 gm. (3K oz.); bread (graham), 30 
gm. (1 oz.); fruit, small portion as sauce without 
sugar; salad, vegetable or fruit, radishes, pickles. 
Banting's Cure (very severe) : 

Breakfast, 8 a.m.; 150 to 180 gm. (5 to6oz.) meat or 
broiled fish (not a fat variety of either) ; a small bis- 
cuit or 30 gm. (1 oz.) dry toast; a large cup of tea or 
coffee without cream, milk or sugar. 
Dinner, 1 p.m.: Meat or fish as at breakfast, or any kind 
of game or poultry, same amount; any vegetables 
except those that grow under ground, such as potatoes, 
parsnips, carrots or beets; dry toast, 30 gm. (-1 oz.); 
cooked fruit without sugar; good claret, 300 c.c. 
(10 oz.). Madeira or sherry. 
Tea, 5 p.m. : Cooked fruit, 60 to 90 gm. (2 to 3 oz.) ; one 
or two pieces of zweiback; tea, 270 c.c (9 oz.) without 
milk, cream or sugar. 
Supper, 8 p.m.: Meat or fish, as at dinner, 90 to 120 c.c. 
(3 to 4 oz.); claret or sherry, water, 210 c.c. (7 oz.). 
Fluids restricted to 1050 c.c (35 oz.) per day. 
Oertel's Cure. — In Oertel's obesity cure great stress is laid 
upon the condition of the heart and any circulatory changes, 
large meals being distinctly apt to embarrass either. 

The object of the diet is to furnish food and exercise so 
that the patient may burn his own body fat, but not allow 
any destruction of protein which is not fully supplied by the 
diet. 

Each case must be studied with a view to seeing what 
function must be safe-guarded while the process of reduction 
is in progress. 

Oertel's calculations for the needs of the body are: 





Protein, 
grams. 


Fat, 
grams. 


Carbohydrates, 
grams. 


Calories. 


Minimum . 
Maximum . 


• 156 (5M OZ.) 
i 170 (5% oz.) 


25 ( % oz.) 

45 (iKoz.) 


75 (2# oz.) 
120 (4 oz.) 


Il80 
1608 



Restriction of fluid is an essential part of the treatment 
and while he allows 1500 c.c (i}4 quarts) in average cases, it 
may be best to reduce it to 1250 or 750 c.c (41 to 25 oz.). 



OBESITY 499 

Solid foods must be- taken alone and fluids between meals , 
five or six meals are given in the day. 

Exercise is regarded as of equal importance with diet, and 
ordinarily out-of-door exercise of five hours per day is in- 
sisted upon, beginning with what the patient is up to and 
gradually increasing. In European health resorts hill- 
climbing is much in vogue, there being four different grades, 
as follows: 

First. incline from o to 5 degrees. 
Second. " " 5 to 10 " 

Third. " " 10 to 15 " 

Fourth. " " 15 to 20 " 

At first the patient takes only the first or second climb, 
avoiding overexertion and walking about from one to two 
hours, not taking into account the down-hill return. 

If necessary, from the patients condition, the first walking 
must be on level ground, and where even this causes cardiac 
or respiratory distress it is especially useful to have them 
given resisting exercises to all muscles, beginning with 5 to 10 
movements to each set, increasing the amount of resistance 
and the number of movements up to 20 to 25 for each set of 
muscles. If there is angina, great caution must be used in 
all exercises, not to allow anything that will materially raise 
the blood-pressure. 

After sufficient reduction in weight has been accomplished 
Oertel puts patients on an "after-diet" as follows: 

Breakfast: Coffee or tea with milk, 150 to 200 c.c. (5 to 

6 T /> oz.); bread, 75 gm. {2]/ 2 oz.). 
Midmorning: Soft eggs, one or two, or 30 to 40 gm. 
(1 to i}4 oz.); meat, 100 gm. (33^ oz.); wine or port, 
50 c.c. (1% oz.); a little bread. 
Dinner: Soup, 100 c.c. (sH oz.); meat or fowl (not fat), 
150 to 200 gm. (5 or 6 oz.); fish, cooked without fat, 
100 gm. (3 oz.); dessert, fruit, 100 to 200 gm. (3 to 
6 T A oz.) ; light wine or beer, 160 to 250 c.c (5 to 8 oz.) ; 
water. 
Midafternoon: Coffee or tea, 150 to 200 c.c. (5 or 6 oz.); 
water, 250 c.c. (8 oz.) ; bread, 30 to 60 gm. (1 or 2 oz.). 
Supper: Meat as at dinner, or eggs; bread, 30 gm. 
(1 oz.); small amount of cheese, salad or fruit; wine 
or beer, 300 to 500 c.c. (10 to 16 oz.), with water or 
not. 
Ebstein's Dietary. — Ebstein modified existing obesity 
cures by allowing a considerable amount of fat but notably 
restricting the carbohydrates, forbidding all sugar, sweets 
and potatoes, but allowing 180 to 210 gms. (6 or 7 oz.) of 



500 DISTURBANCES OF NORMAL METABOLISM 

bread. Vegetables that grow above ground are allowed and 
all sorts of meat, especially is fat meat permitted. Fats 
are allowed, 120 to 180 gms. (4 to 6 oz.) per day. Three 
meals with the heartiest at midday. 

Breakfast: One large cup of black tea, without cream or 
milk, or sugar; white or brown bread, 60 gms. (2 oz.) 
with plenty of butter. 
Dinner: 2 p.m. Clear soup, meat 120 to 180 (4 to 6 oz.) 
with gravy and fat meat is especially recommended; 
vegetables in abundance (as noted above) ; small 
amount of fresh or stewed fruit (without sugar) or 
salad ; two or three glasses of light white wine. Shortly 
after dinner a cup of tea is allowed with sugar or 
milk. 
Supper: 7.30 p.m. Large cup of tea, without sugar or 
milk; one egg with or without a small portion of meat, 
preferably fat. Occasionally a little cheese or fresh 
fruit 
Total values: Protein, 100 gm. (33^ oz.); fat, 85 gm. 
(3 oz.); carbohydrate, 50 gm. {2% oz.). 

Schweninger's Dietary. — Absolutely no fluids are allowed 
with meals but must be taken at least two hours afterwards. 
Breakfast, 8.00 a.m. Meat, eggs or milk. 
Lunch, 10.30 a.m. Fish or meat with 90 c.c. (3 

oz.) light wine. 
Dinner, 1.00 p.m. Meat, vegetables and fruit. 

Supper, 7.00 p.m. Meat, stewed fruit or salad 

and 90 c.c. (3 oz.) white wine. 
As little bread as possible to be taken. Exercise is to be 
taken frequently during the day, in fact some time after 
each meal. 

Germain-See Diet. — The chief recommendation in this 
diet is that fluids are forced and no wine allowed. 
Tibbies Milk Cure: 1 

Breakfast: Milk, 500 c.c. (1 pint). 

Lunch: Meat, 180 gm. (6 oz.) ; plate of boiled vegetables 
(bread and potatoes are not allowed); junket, 250 
gm. \y 2 pint). 
5 p.m.: Junket, 250 gm. (}4 pint); two cups of tea, very 

little sugar. 
Dinner: Milk, 500 c.c. (1 pint); two apples, 1800 cal- 
ories. 
Tibbies has used this with great success. 
Total values: 

Protein. Fat. Carbohydrate. Calories. 

100 gm. (33^ oz.) 60 gm. (2 oz.) 50 gm. (i% oz.) 1800 

1 Tibbie: Diet in Health and Disease, p. 462. 



OBESITY 501 

Salisbury Method. — In cases of obesity with carbohydrate 
dyspepsia accompanied as it is by a great amount of flatu- 
lence, it is always advantageous to reduce the carbohydrate 
intake to a minimum. At times it may be necessary to go 
still further and put such a patient on a diet that offers no 
substance for fermentation. Such a diet is Salisbury's. In 
this only finely chopped beef and hot water or weak tea are 
allowed. 

One hour before breakfast a pint of water is to be drunk 
hot, also one and a half hours before dinner and supper. 

Breakfast: 180 to 250 gm. (6 to 8 oz.) finely chopped 
meat, made into cakes or broiled. A pint of water, 
plain or flavored with a little tea, coffee or orange 
juice, without sugar. 
Dinner and Supper the same as breakfast. 

If patients are faint between meals, broth or a little 
chopped meat is allowed. The amount of meat is increased 
up to one pound (500 gm.) at each meal, but no more. This 
can be kept up for a considerable length of time, but ordi- 
narily a few days or a week is sufficient, after which other 
meats may be allowed, also eggs, rice, baked potato and a 
little stale or toasted bread. 

Later green vegetables are added and gradually the 
patient returns to a full mixed diet, keeping down the carbo- 
hydrate intake to the minimum and permanently excluding 
all sugars and sweets. 

Tower-Smiths Modification of Salisbury Diet. — First stage 
fourteen days. The diet is restricted to three pounds of lean 
beef, one pound of codfish and six pints of water, preferably 
hot. This is divided into four meals. The water should be 
taken as follows: 

1. One pint early morning. 

2. One pint half an hour before breakfast. 

3. One pint an hour before midday meal. 

4. One pint before the afternoon meal. 

5. One pint before the evening meal. 

6. One pint at bedtime. 

Condiments are allowed. The meat contains 286 gm. 
{9/4 oz.) protein, 43 gm. (i}4 oz.), nitrogen. 

Second stage: Twenty-one days. 

The water is now but four pints, the beef and fish together 
but three pounds. Any meat-free fat or fish of the non-fatty 
variety may be used. Bread, as before 60 to 90 gm. (2 or 
3 oz.). Dry white wine or tea is also allowed. 

No person with organic disease should take this cure, and 
if not carefully carried out it may result in the production of 
mental disturbance amounting at times to mania. 



502 DISTURBANCES OF NORMAL METABOLISM 

Galisch's Cure. 1 — The principle of this diet is to give very 
little food at night so that during sleep the body has less food 
to store up. 

Diet. — Early a.m. Tea with white bread and butter. 

10 a.m. One egg with a little bread and 
butter, 
i p.m. Meat and vegetable, a little sauce, 
potato, salad and stewed fruit. 
Afternoon: Coffee with zweiback or white bread 
and a little butter. 
Evening: A small piece of bread and butter. 
A little beer or wine. 

At breakfast and dinner enough is allowed to satisfy the 
appetite, but during the afternoon for a few days the patients 
are very hungry, this disappears, however, when more break- 
fast is taken. 

When the patient is down to normal weight, more food is 
cautiously allowed at night. Brauer recommends at the 
outset a Karell cure for ten days, then an after-cure given 
in bed. 2 

Folin-Denis Method of Reduction. 3 — Since the essence of 
the successful reduction method in obesity lies in keeping 
the intake of energy below that of the output, complete fast- 
ing would theoretically, at least, accomplish this purpose 
most promptly. Unfortunately this is not possible without 
the production of symptoms such as headache, nausea and 
dizziness which indicate abnormal metabolic conditions. It 
was found that these symptoms could be easily made to 
disappear if even a little food was given. On account of 
these symptoms it has been the habit to underfeed the obese 
in reduction cures rather than starve them in order to cause 
a loss of weight due to the actual oxidization of the body fat. 

In the course of observations on the voluntary fasting of 
two exceptionally obese patients of the Massachusetts Gen- 
eral Hospital in Boston, Folin, and t)enis noted " the usual 
development of the indications of 'acidosis,' that is, an in- 
creased elimination of acetone, aceto-acid and particularly 
of j8-oxybutyric acid and ammonia in the urine. In one of 
the subjects the figures were exceptionally high, amounting 
to over 1 8 grams of /3-oxy butyric acid and no less than 2.5 
grams of ammonia-nitrogen during the fourth day of starva- 
tion. The appearance of such products in these amounts is 
in accord with the widespread scientific belief that the 

1 Med. Klin., 1912, viii, 1909. 

2 Deut. med. Wchnschr., 19 13, xxxix, 1336. 

3 Jour. Biol. Chem., 1915, xxi, 183. 



OBESITY 503 

'acetone bodies' are derived chiefly from incompletely oxi- 
dized fat. When the obese are compelled to depend on their 
store of fat for maintenance, one might reasonably expect 
these intermediary products to 'crop out.'" 

In order to relieve the subjective symptoms associated 
with this fasting acidosis, Folin and Denis interrupted the 
period of complete starvation by a period of very moderate 
diet, just sufficient to cause the disappearance of the "ace- 
tone bodies" from the urine. 

Thereupon a second fast was begun. Here the striking 
observation was made that the acidosis did not manifest 
itself anew until the third day of this fast, and the patient 
felt well until the fourth day. After an interspersed repeti- 
tion of "low" diet a third fast was begun five days later. 
Here again the onset of acidosis was even slower than during 
the second period. These facts, supported by confirmatory 
evidence in a similar case, have suggested to the observers 
that with regard to the complete oxidation of body fat in 
starvation, the human organism is capable of at least a 
certain amount of adaptation, and that it is this individual 
factor rather than the tendency to obesity or the extent of 
the fat deposits in the body which chiefly determine the onset 
and the degree of acidosis. Folin and Denis conclude that 
one of the effects of repeated fastings is habituation to the 
complete oxidation of mobilized body fat, and a consequent 
retardation of the development of acidosis. 

These results suggest, in the words of their discoverers, 
that one perfectly safe, rapid and effective method of reduc- 
ing the weight of very obese persons is by a series of repeated 
fasts of increasing duration, the ammonia or /3-oxybutyric 
acid determination being used as a guide to the length of each 
fast. 1 

This might be said to be the last word in obesity cures. 

Exercise and Massage. — Exercise and massage form part 
of the treatment in every case. Massage does not remove 
fat but only helps to keep the muscles in good condition. 
Exercise often with extra clothing helps to burn up the excess 
of fat, but patients must be careful that the increased appe- 
tite which follows exercise does not cause them to regain at 
the next meal all they have lost. 

Water in Obesity. —Just a word in closing on this mooted 
subject. Water per se does not increase weight unless there 
is chloride retention, but it acts indirectly to increase weight 
by making the swallowing of food more easily accomplished 
so that one is apt to eat more ; water also increases the appe- 

1 Jour. Am. Med. Assn., October 23, 1915, p. 1462. 



504 DISTURB A NCES OF NORMA L ME TA BOLISM 

tite. Denning, 1 who investigated this question, found that 
the amount of water taken exerts very little effect upon 
either the production or loss of fat. Von Noorden probably 
voices the rational view of the question in saying that the 
restriction of water is not important except in four condi- 
tions: (i) In cases with weak circulation; (2) at the com- 
mencement of an obesity cure to make a mental impression 
on the patient, for by restriction of fluids loss of weight is 
greater; (3) when reduction of water causes less appetite 
for fat-producing foods (e. g., water after sweets); (4) when 
the sweat excretion is excessive, the water intake should be 
reduced to 1100 c.c. (2J pints) per day. 

GOUT. 

Although a detailed discussion of the etiology of gout is 
not a part of a book on dietetics, a certain understanding of 
the causes producing this disease are essential to an intelli- 
gent application of dietary principles, so that even at the 
risk of repeating what many of the readers already know, 
enough must here be incorporated to accomplish this end. 

The final word has not been said in the biochemistry of 
gout and we are a long way still from understanding much 
about it, yet it can be definitely stated that whatever else 
may be at fault, the inability of the organism to properly 
metabolize the food purines is primarily disturbed, according 
to most authorities. In some instances, possibly in most, 
there is also an accompanying failure in excretion due to de- 
ficient renal function; indeed many authorities assert that 
this renal complication is the chief factor in the precipitation 
of gouty symptoms. So long as elimination is good great 
increase of uric acid productions can occur without there 
being any resulting gouty symptoms. This actually is 
shown to be the case in lobar pneumonia and acute leu- 
kemia, where the percentage of uric acid in the blood is often 
very high, yet no symptoms referable to it are found, as the 
excess is prevented from backing up, through sufficient 
elimination. That the amount of uric acid in the blood is 
the index of a disturbed purine metabolism is course of 
generally believed but that uric acid is the only substance 
at fault seems improbable. Of course the cogeners of uric 
acid, xanthin, hypoxanthin, guanin, theobromine, etc., are 
all included in the generic term "uric acid." Hence we see 
that it probably takes at least two factors to account for gouty 
manifestations. First, increased uric acid production through 

1 Zeit. f. Diet und Physik, Therap., ii, 292. 



GOUT 505 

perverted metabolism of purine bases and second, a defi- 
cient excretion. In- certain cases of clinical gout the excre- 
tion of exogenous uric acid is not always delayed as shown 
by Magnus-Levy, Wintraud, Rommel, Pratt and Rosen- 
bloom. 1 

. McClure 2 after a study of uric acid in gout comes to the 
following conclusions : 

(i) More than 3 mg. of uric acid per 100 c.c. of blood 
with the patient on a purine-free diet is a symptom of gout 
but is not diagnostic of the disease. 

(2) No relation exists between the amount of uric acid 
and total non-protein nitrogen found in the blood of gouty 
persons. 

(3) A marked retention of non-protein nitrogen is not 
frequent in gout. 

(4) The excretion of exogenous uric acid by normal, by 
arthritic and by gouty persons varies greatly both in amount 
and duration. 

(5) The retention of exogenous uric acid is a symptom of 
questionable importance in the diagnosis of gout. 

The source of blood uric acid is twofold : 

1. That derived from catabolism of the body tissue 
nucleins (the nuclei of cells) called endogenous uric acid. 

2. That derived from the foods, called exogenous uric 
acid. 

Naturally there is always a certain amount of uric acid in 
the blood even on a uric acid-free diet due to the breaking 
down of cell nuclei. This, however, should not exceed 0.5 
to 1 mg.per 100 c.c. of blood and is of no pathological import- 
ance, provided elimination is sufficient. In severe neph- 
ritis, even though the uric acid production is not increased, 
the difficulty in excretion results in a uricacidemia. This, 
however, does not by any means invariably produce gouty 
manifestations and in fact few cases of chronic Bright's show 
them. This fact seems to prove that there is still another 
element in the production of gout that has thus far eluded 
us. Duckworth 3 says that gout is caused by an excess of 
uric acid in the blood but further states that it is the result 
of a special disturbance of the nervous system, there being a 
trophic center for joints in the medulla and the sudden pre- 
cipitation of an attack is due to nervous causes, given the 
underlying uricacidemia and poor elimination. 

Ebstein showed that in the deposition of the sodium biu- 
rate in the joints a destructive process always precedes the 

1 Jour. Am. Med. Assn., 1918, lxx, 285. 

2 Tr. Am. Assn. Phy., 1917, xxxii, 186. 

3 Jour. Advance Therap., New York 1913. 



506 DISTURBANCES OF NORMAL METABOLISM 

deposition of the salts due to the local effect of the circula- 
ting uric acid. Today it is easier to believe that this pre- 
liminary destructive process may be rather due to some pro- 
cess of chronic infection and the association of this with 
what are apparently gouty lesions must not be forgotten. 
Infection may play a much more important role than we 
have been wont to imagine and may supply the missing 
link in the chain of evidence that might connect the uric- 
acidemia with the arthritic changes. This is admittedly an 
elusive factor in the production of gout for which the nervous 
system is blamed by some. In other words uricacidemia 
plus chronic infection may result in the deposition of 
biurate of soda in the connective tissues, so-called "gout" — ■ 
whereas chronic infection plus certain other unknown condi- 
tions may result in arthritis of other kinds — the so-called 
chronic rheumatoid arthritis, etc. 

Garrod 1 says that there are only three established facts 
in gout. 

1. The deposits in the tissues are sodium biurate. 

2. The blood contains an excess of uric acid. 

3. Except during attacks there is no excess output of uric 
acid in the urine (although there is an increased percentage 
of it in the blood almost constantly). 

In patients past forty-five or fifty, it is frequently the cus- 
tom to ascribe almost all irregular and unexplained aches and 
pains to gout, but undoubtedly innumerable cases of non-gouty 
arthritis, luetic lesions and occasionally tuberculous joints 
are treated as gout, so that a careful diagnosis is of special 
importance if one wishes to be successful in the dietetic 
handling of this disease. There is also another reason for 
an accurate diagnosis, in that to put a patient on a purine- 
poor diet for a .prolonged period, without adequate cause, 
is not without its dangers, for nowadays we have come to 
know that some disease conditions are brought about by a 
lack of certain food elements in the diet and one has only to 
mention scurvy and beriberi, both due to the absence of 
accessory food substances sometimes called "vitamines" to 
realize that a continuous diet which almost entirely leaves 
out these useful food factors may result in damage to the 
organism and " until these factors are known and reckoned 
with, rules of diet on scientific lines are not possible." 2 

So much then for a brief theoretical discussion of the under- 
lying facts which must govern us in the construction of a 
gouty diet, the object of which is to prevent the development 

1 Lancet, 1913, i, 1790. 

2 Garrod: Lancet, 1913, p. 1790. 



GOUT 507 

of a gouty condition and to control the active symptoms of 
an acute attack. We see that the best we can do is to give 
a diet which will not increase the uric acid in the blood, on 
account of there being a disjointed eliminative system, but 
at the same time keeping in mind that a gouty person cannot 
stand protein starvation any better than anyone else, al- 
though such an one is probably improved by keeping the 
protein of the diet somewhere near the low level suggested 
by Chittenden, not over 50 to 70 gm. protein per day. This 
latter provision is also important, as with a complicating 
contracted kidney there is apt to be more or less nitrogen 
retention. Another further consideration in the regulation 
of the diet is the fact that we must keep in mind the general 
nutrition of the patient, who, if already poorly nourished 
will hardly improve if his nutrition is still further disturbed 
by an insufficient diet. One must also diet with reference 
to complicating obesity or glycosuria both not infrequently 
accompanying conditions of gout. 

Before proceeding to a discussion of the foods and actual 
dietaries in gout, it would be quite worth while quoting von 
Noorden's 1 and Schleip's 2 methods of making a diagnosis of 
actual gout by the dietary regulation. Their practice is to 
put a patient on a purine-free diet for five days and estimate 
the urinary uric acid. The normal person on such a diet 
should daily excrete an average of 0.45 gm. uric acid (endo- 
genous). If during this period less uric acid is excreted each 
day than is normal, gout may be suspected. A definite 
amount of purine-containing food is then added for two days, 
400 gm. of beef, weighed raw (or 50 gm. thymus gland). 
The 800 gm. of beef (or 100 gm. thymus) (the supply for two 
days) are equivalent approximately to 1.4 gm. uric acid, of 
this 0.7 gm. may be expected to show in the urine in twenty- 
four hours after the last day on which the meat was taken. 
If this extra uric acid elimination is below 0.7 gm. or is de- 
layed in elimination over several days, the uric acid from this 
amount of beef or thymus is too much and is beyond the 
individual's tolerance. If this is so, repeat the test, using 
one-half the amount of meat ; when the tolerance is found it 
shows how much purine food can be given daily with the 
expectation of complete elimination and without causing a 
uricacidemia. As compared with the normal individual, 
Pratt has shown that a dose of 100 gm. of meat for a gouty 
person causes the blood uric acid curve to rise and remain 
up much longer. 

1 Gout, p. 73. - Berl. klin. Wchnschr., 1905, 42, 1297. 



508 DISTURB A NCES OF NORMA L ME TA BOLISM 

Umber's 1 elimination curve is deterimned in much the same 
way, as the initial steps are the same but only 200 gm. of 
meat are given, or one can use 25 gm. thymus. The length 
of time for complete elimination is noted. Normally this 
excess uric acid should be eliminated in twenty-four hours. 
In mild cases of gout it may be delayed over three or four 
days, in more severe cases five or six days may be required 
before the normal limit is reached. The number of days it 
takes to eliminate the extra with a return to the normal level 
will indicate the period there should be between purine days. 
This will often show that a mild case of gout should take 
meat or purine food only twice a week and more severe cases 
only once a week or at even longer intervals. Clinically 
this plan of giving meat or purine food only once every few 
days has long been in use and has been found a satisfactory 
way to allow purine food. The use of thymus instead of 
beef is advised by Fine, for in such large amounts as 400 to 
800 gm. of beef, the excess of meat alone is apt to delay the 
elimination of the uric acid. As already indicated 50 gm. of 
thymus yields the same amount of uric acid as 400 gm. of meat. 

The diagnosis of uricacidemia is made now so easily by 
means of the direct examination of the blood for uric acid by 
Folin's method, that it can readily be determined whether an 
excess of uric acid is circulating in the blood or not. The 
longer method described is therefore less useful for diagnos- 
tic purposes than it is for the determination of the length of 
time required for uric acid elimination and its degree after 
a definite dose of purine. 

Foods in Gout. — The actual dietary management of acute 
or chronic forms of gout will be given under a separate head- 
ing, but it is necessary to indicate here not only the best 
forms of protein, fat and carbohydrate, but what is quite as 
important, those forms which must be especially avoided. 
Protein food derived from glandular organs is especially to 
be avoided as containing the higher percentages of nucleic 
acid, derived from cell nuclei in which such organs abound. 
Soups made with meat stock may all be labeled " poison " 
for gouty people, containing as they do such a high percent- 
age of extractives, almost a solution of purines. In fact 
these patients might much better eat the meat from which 
the soup is ade mthan the soup itself and a safe rule for them 
is to forget that such a thing as a clear or meat soup exists. 
Rich gravies and sauces should also be omitted from the diet 
as should condiments of all sorts. Only the simple hydro- 
carbons should be taken, such as butter, cream and vege- 
table oils. 

1 Lehrbuch d. Ernahrung u. d. Stoffewec. Krankht., Berlin, 1909. 



GOUT 509 

Carbohydrates. — Rich or concentrated sweets should be 
avoided as tending to disturb digestion and cause flatulence, 
but a moderate amount of simple sweetened food is allowable 
as palatable, of high caloric value and purine-free. All 
foods that have a well-earned reputation for indigestibility, 
quite independent of their constituents, must be avoided. 

Salt. — While it is not necessary to resort to extreme limit- 
ation of common salt, it should be kept at the lowest possible 
level compatible with palatability, for Lindsay 1 says that 
sodium has the effect of throwing sodium biurate out of solu- 
tion from the blood, and it is known that the deposit of 
sodium biurate occurs in a distinct ration to the amounts of 
sodium salts in the various tissues in the body. The joints 
and tendons which are most highly sodium-containing are 
the most frequent sites of the uratic deposits, Hence keep- 
ing down the soda intake to the lowest level reduces, theor- 
etically at least, the chance for a deposit of sodium biurate 
in the joints. 

Alcohol. — Undoubtedly the gouty patient is better with- 
out any alcohol whatever, unless he has been a steady user 
of it, in which case a little whiskey, well diluted, preferably 
with an alkaline table water, is allowable. The writer has 
seen cases in which the entire withdrawal of alcohol, in 
patients accustomed to taking considerable quantities 
caused a decided increase in the symptoms, which were made 
distinctly less when a small amount of alcohol was again 
allowed. Any use of alcohol should be discontinued as soon 
as possible, and sweet wines, beers or champagne are es- 
pecially bad, and should never be allowed. German clini- 
cians, however, allow light Rhein wines in moderation, but 
the gouty subject is better without any form of alcohol. 

Coffee, Tea and Cocoa contain considerable purine. This 
is changed in the digestive processes into bodies which have 
very little do do with uric acid and while small amounts of 
these beverages are allowable, any excess of them tends to 
disturb digestion and should be interdicted. Tea and 
coffee should not be boiled but made as a fresh infusion if 
used at all. Many recommend the use of one of the " caf- 
feine-free" coffees (see p. 249). Having discussed the 
u dont's" of gout, we may now consider what foods and in 
what proportion they are allowable in the construction of a 
gouty diet. From what has already been said it is clear 
that the object sought in prescribing a gouty diet is to either 
omit all purine foods or to keep them down to a low level, 
preferably a known low level. Many so-called purine-free 

1 Gout, Oxford Press, 19 13. 



510 DISTURBANCES OF NORMAL METABOLISM 

foods in reality contain a very faint trace of purine which r 
however, may be disregarded from a practical stand-point. 
Diet in Acute Gout or Podagra. — During the first twenty- 
four to forty -eight hours of an acute attack in sthenic indi- 
viduals, it is a wise plan (after a thorough emptying of the 
intestinal canal) to starve the patients completely, giving 
them only large amounts of water (preferably salines) pro- 
vided they have not a coexisting high blood-pressure when 
less water should be allowed, but in any instance enough 
should be taken to act as a tissue diluent and for its flushing 
effect. If patients absolutely insist on food, a glass gf milk 
may be given four times a day but nothing else. During 
this period, if accompanied by proper medication large 
amounts of uric acid may be eliminated. The patients may 
then be put on a purine-free diet, preferably a liquid or semi- 
solid diet, consisting of milk, eggs, either plain or as junket 
and custard, limiting the milk to iooo c.c. and the eggs to 
three and giving a little every three hours. This limitation 
of the protein is advisable because there is usually or often 
an accompanying contracted kidney which alone is capable 
of causing a nitrogen retention. After the acute symptoms 
have passed one may give a soft purine-free diet and later 
modify this according to the plan for chronic gout. 

Purine-free Foods. — Eggs (including caviare), milk, bread 
(only white, not graham or entire wheat bread), butter, bis- 
cuits, cereals (hominy, rice, farina), cream, sugar, syrup, jam 
and marmalade, cake, cream soups, potatoes (have slight 
amount of purine), cauliflower, cabbage, lettuce, egg plant. 
Desserts. — Nuts, cheese, ice-cream, water ices, cake, rice, 
bread, farina, cornstarch or tapioca puddings, custards. 

Drinks. — Sweet cider, grape juice, unfermented fruit 
juices generally. 

Soft Purine-free Diet. Use for Main Diet. (Vanderbilt 
Clinic.) 

6.00 A.M. Milk, 180 c.c. (6 oz.). 

8.00 a.m. Breakfast — Milk, 180 c.c. (6 oz.); one and a 
half slices of bread and one pat of butter; 
two tablespoonfuls of cream of wheat or 
wheatena with 6o c.c (2 oz.) cream and 2 
tablespoonfuls of sugar; one soft-boiled egg. 
12.30 p.m. Dinner — Milk, 180 c.c. (6 oz.); one soft- 
boiled egg; potato with cream, 30 c.c. (1 oz.) 
and pat of butter; lettuce or young cabbage 
with dressing; i}4 slices of bread, with one 
pat of butter. 
3.30 p.m. Milk, 180 c.c. (6 oz.). 



GOUT 511 

6.00 p.m. Supper — One soft-boiled egg; milk, 180 c.c. 
(6 oz.); 2y 2 tablespoonfuls of rice with 
cream, 30 c.c. (1 oz.) and one tablespoon- 
f ul of sugar ; crackers with one pat of butter ; 
one cube of cheese (2 inches) ; one cup of 
weak tea with cream, 30 c.c. (1 oz.), and one 
teaspoonful of sugar. 
9.00 f.m. Milk, 180 c.c. (6 oz.). 
This gives: Protein, 80 gm. (2% oz.) ; fat, 112 gm. (3% 
oz.) ; carbohydrate, 207 gm. (7 oz.) ; calories, 2300. 

In chronic gout we are not compelled to combat the severe 
pain and discomfort seen in the acute form which necessi- 
tates a drastic dietary regimen to help in cutting it short, so 
that we may proceed more leisurely to an accurate deter- 
mination of just which foods an individual case will do best 
upon. It is here that we cannot do better for our guidance 
than refer freely to von Noorden's clear statements. Just 
as in diabetes we put the patient on a strict carbohydrate 
free food until the urine is sugar-free and then by adding 
small amounts of carbohydrate, determine the carbohydrate 
tolerance, so in gout we must put a patient on a purine-free 
diet and then by additions of purine-containing foods, de- 
termine his tolerance for purine. 

1. The purine-free diet is also called the main diet. 

2. The accessory diet consists of foods containing purines. 
For the main diet it is convenient to use the soft-purine- 

free diet already given and this should be used for several 
days or until the low level of uric acid output is reached either 
presumably or as determined by analysis of the urine. When 
this point is reached then we may make use of the accessory 
diet to some extent. 

In the accessory diet von Noorden takes 100 gm. (33^ oz.) 
of roast beef as the unit and reckons other meats, fish, fowl, 
etc., on this basis as follows: 

100 gm. (33^ oz.) of roast beef, veal, mutton, lean pork, 
ham, tongue, venizon, rabbit contain the same amount of 
purine as 200 gm. (6}4 oz.) fish, except the salmon family, 
or 200 gm. (6>^ oz.) lobster or crab, or 24 oysters, or 2 pig- 
eons, or 1 spring chicken, or y 2 capon, or 1 guinea hen, or 
yi duck, or y^ goose. 

So in ordering the accessory diet, we can advantageously 
use one or more portions of these various purine-containing 
foods. 

When we have found by trial how much of the accessory 
diet the patient can eat without getting gouty symptoms, 
(which can also be checked up by urinary estimations of 



512 DISTURBANCES OF NORMAL METABOLISM 

uric acid), it is always a good plan to put in one or two purine- 
free diet days a week, depending on the patient's tolerance, 
comparable to the diabetic fast or green days. Just as there 
are some cases of diabetes who cannot take any carbohy- 
drate food or only minimal amounts without showing sugar 
in the urine, so some cases of gout can stand little or no 
purine food without presently showing symptoms. These 
cases must walk a narrow dietetic path, so far as the use of 
purine foods is concerned, and many do well only so long as 
they are kept on a purine-free diet. Complicating obesity or 
diabetes must be treated according to the principles laid 
down for these conditions in addition to their gouty diets 
and often it is no easy matter to take proper account of all 
these complications without fairly starving the patient. 
Often the most prominent condition must be dieted first 
without much reference to the other conditions present. 

It must also be remembered that in a small percentage of 
cases no form of dieting seems to do good and the patients 
go on from bad to worse, as they are unable to dispose of 
even the purine products of their own metabolism. 

There are certain individuals in whom it seems fairly cer- 
tain that gout is present in some degree and in whom it is 
wise to institute a diet suitable for such mild cases which 
will not impose too great a dietary hardship, while at the 
same time keeping the purines down to a very low level. 
This would be distinctly useful in conditions which seem 
almost certainly due to a uricacidemia (although there are no 
definite joint symptoms), such as gouty skin lesions, long- 
standing catarrhs of the respiratory tract, etc., mostly in 
middle-aged or really old people. Of such a diet the follow- 
ing is an example, made up of the purine-free articles of diet 
or those with a small amount of purine prepared in the least 
objectionable way. 

Diet in Gouty Diathesis. 

Breakfast: Fruit, cooked or raw; cereal, any one, but 
preferably wheat preparations; white bread, toast, 
rolls or muffins and butter; eggs, cooked as desired 
except fried; cup of weak tea, cocoa or coffee, largely 
milk, with sugar; a little marmalade if there is no 
indigestion. 
Luncheon or Dinner: Soup, cream or puree of vegetables 
(no meat) ; egg, entree; meat or fish, never more than 
once a day, in small amounts, the meat best boiled 
in two waters — beef, mutton, chicken, ham; vege- 
tables potatoes (white or sweet), cabbage, spinach, 
egg plant, corn, sprouts, beet tops, lettuce, rice, 



GOUT 513 

macaroni, noodles, cauliflower, string beans, celery, 
(peas, lima beans or white beans, if there are no ac- 
tive symptoms), no stock to be used in sauces: des- 
serts, fruit cooked or raw; all simply prepared des- 
serts, not too sweet, ice-cream, simple cake, Ameri- 
can, cream, Swiss or Pot cheese; beverages, milk, 
unfermented fruit juices, e. g., grape juice, apple 
juice, cider, alkaline mineral waters in small amount; 
plain water. 
Mineral Waters. — Much has been written on the subject 
of the efficiency of cures at the various mineral spas or the 
taking of either the natural or artificial mineral waters at 
home and at one time or other many of the mineral springs, 
alkaline or saline, have enjoyed considerable vogue and still 
do. The first indication is for the use of considerable 
amounts of water for the mechanical effect of ''flushing the 
system" and also for the beneficial effect on coexisting gastro- 
intestinal catarrh or hepatic congestion, but there is little 
evidence that these waters otherwise effect the elimination 
of uric acid, and on the contrary, prolonged use of them 
often acts in the reverse way and therefore should be dis- 
couraged. Short courses of water cures may be taken at 
Vichy, Marienbad, or Carlsbad, but should not be long- 
continued. In the United States, Saratoga, Hot Springs, 
Va., and White Sulphur Springs furnish treatments very 
similar. 

The Purine Bodies in Various Foods. 1 
Fish: Vegetables {Continued) 

Cod 0.5 Beans (Haricot) . . . . 0.63 

Salmon . . . . 1.1 Asparagus 0.21 

Halibut . . . . 1.0 Cabbage 0.0 

Meat: Lettuce 0.0 

Beef 1.3 to 2.0 Cauliflower 0.0 

Fat 1.1 Onions 0.09 

Mutton . . . . 0.96 Tapioca . . . . ' . . 0.0 

Fat 0.0 Special foods: 

Veal 1.1 Milk 0.0 

Fat 0.0 Butter 0.0 

Pork 1.2 Eggs 0.0 

Fat. 0.5 Cheese (fat) 0.0 

Ham 1.1 Drinks: 

Meat soups, varying large amounts: Beer 0.12 

Chicken . . . . 1.2 Ale 0.14 

Vegetables: Porter 0.15 

Potatoes . . . . 0.02 Per pint (500 c.c.) 

Rice . . . . . 0.0 Tea 1.2 

Flour (white) . . . 0.0 Cocoa 1.0 

Bread (white) . . . 0.0 Chocolate 0.7 

Oatmeal . . . . 0.53 Coffee . . .. . . . . 1.7 

Peas 0.39 Claret 0.0 

Lentils 0.38 Sherry 0.0 

Port 0.0 

*J. Walker Hall: The Purin Bodies in Food-stuffs, etc., London. 1903, 2d 
edition, revised. 
33 



514 DISTURBANCES OF NORMAL METABOLISM 

Radio-active waters have come into great popularity and 
in some quarters hopes have run high in consequence, some 
authors praising it extravagantly as of distinct value in doses 
of iooo Mache units a day, increasing to 5000 to 10,000 
m. u. The theories that account for its usefulness as sum- 
marized by Burnham 1 are: 

1. Activation of ferments causing the oxidation of the 
uric acid and its further disintegration into C0 2 and am- 
monia. 

2. Direct action on the uric acid, the emanations causing 
its solution and disintegration. 

3. Increased activity of the kidneys by means of which 
excess uric acid is excreted by the blood. 

On the other hand, Chace and Fine 2 conclude that radium 
emanation in concentration of at first 0.5 and later 100 m. u. 
per liter of air, radium drinking water and injection of sol- 
uble radium bromide in none of their cases snowed any in- 
fluence whatever upon the uric acid concentration of the 
blood, nor was the output of uric acid in the urine definitely 
increased. 

DIET FOR LEANNESS OR FATTENING CURES. 3 

In discussing this subject von Noorden says that the aver- 
age layman at a glance will undertake to say whether a cer- 
tain individual is normally well developed, too thin or too 
fat ; but as a matter of fact there are other factors which 
must be considered in arriving at this apparently simple 
diagnosis. Thus a person with tuberculosis who is some- 
what overweight is better so, a person with chronic nephritis 
or cardiac disease who is somewhat underweight is better off 
so and under no circumstances should be the subject of fur- 
ther increase in weight. It is also important in arriving at 
the necessity of a fattening cure to know whether the muscle 
substance or the adipose, or both, are too little. 

The first thing of importance in any given individual is to 
know their maintenance diet, i. e., a measure of which may 
be taken as the diet which will keep him in nitrogenous equi- 
librium and at an even weight. Of course this means that a 
certain number of calories will constitute a fattening cure 
for one man, whereas for another who is naturally larger or 
whose work is more arduous it would not even be a main- 
tenance diet. Given the maintenance diet it is important in 
planning a fattening cure to know about what increase in 

1 Med. Rec, New York, 1913, lxxxi, 117. 

2 Washington Med. Jour., 1912, 3, xi, 23; Jour. Pharm. and Exp. Therap., 1914, 
vi, 219. 

3 Adapted largely from von Noorden, "Fattening Cures." 



DIET FOR LEANNESS OR FA TTENING CURES 515 

weight may be counted upon by giving extra calories. Von 
Noorden on the basis of much material has come to the fol- 
lowing conclusion : 

Daily surplus of food Results in a possible average 

or fattening additions. weekly increase in weight of: 

500 to 800 calories 600 to 1000 gm. 

800 to 1200 " 800 to 1200 " 

1200 to 1800 " 1200 to 2000 " 

This surplus of food or fattening addition von Noorden 
calls the "sum of the nutritive units (calories) administered 
in excess of the calculated nutritive demands (maintenance 
diet) of the individual." 

The two essentials in a satisfactory fattening cure are to 
increase, first, the nitrogen surplus, and second, the adipose 
tissue. One without the other does not make a satisfactory 
result. 

In a usual fattening cure with a fair protein ration (100 to 
120 gm. daily) and a fair caloric surplus (30 to 40 percent, 
above the calculated amount of the maintenance diet), one 
may expect a daily retention of nitrogen of from 1 to 3 gm., 
or if the caloric surplus is 40 to 60 per cent, above the main- 
tenance diet one may expect a retention of from 2 to 6 gm. 
nitrogen per day. Nevertheless this added nitrogen does 
not tend to "stick" but is rather soon gotten rid of when the 
excess diet is reduced, and it must be concluded that we are 
"not justified in concluding that by overfeeding alone, with- 
out the cooperation of other factors, a material increase of 
'flesh' (genuine breathing protoplasm) can be forced." 
"The real accumulation of flesh seems to be dependent on 
altogether different factors and seems to presuppose a speci- 
fic predisposition on the part of the organism to accumulate 
flesh, we find a ready tendency to the increase of flesh in: 

"1. The growing organism. 

"2. During convalescence, following the sacrifice of pro- 
tein. 

"3. In muscles (and glands) that are stimulated by exer- 
cise (labor hypertrophy) . " 

The increase of adipose tissue is the other factor to be 
considered in fattening cures and is a much more simple 
matter, as it can be calculated quite accurately on the basis 
of the intake of the surplus over and above the maintenance 
diet, except in certain individuals. 

Foods to be Used in Fattening. — Any of the food elements, 
protein, carbohydrate or fat are capable of increasing the 
weight. 

Protein. — We cannot get patients to take continuously 
excessive amounts of protein, as it is apt to disturb digestion 



516 DISTURBANCES OF NORMAL METABOLISM 

when given in amounts of 150 gm. (5 oz.) per day; the 
optimum in fattening cures probably lies between 100 to 120 
gm. (3^ or 4 oz.) of protein. 

If, as following severe illness or to accomplish severe mus- 
cular work, it is advisable to increase the protein allowance 
above 100 gm. (33^ oz.) it can best be done by adding some 
of the more concentrated protein foods, as their bulk is 
smaller and there is usually less strain put upon all the excre- 
tory organs. Von Noorden's list of foods and amounts 
containing 100 gm. (31^ oz.) protein is helpful in choosing 
an additional protein allowance. 

100 gm. (33^$ oz.) of albumin is contained in the following 
foods : 

Eggs (without the shell), 900 gm. (30 oz.). 

Veal, chicken (weighed raw,) 500 to 550 gm. (16% to 18 
oz.). 

Fish (weighed raw), 500 to 600 gm. (16% to 20 oz.). 

Beef (weighed raw), 480 to 550 gm. (16 to 18 oz.). 

Cow's milk, 3000 to 3500 (3 or 3^ qts.). 

Cream cheese, 400 to 450 gm. (13 to 15 oz.). 

Sanatogen, 105 gm. (3K0Z.). 

Tropon, no gm. (3% oz.). 

Somatose, 120 gm. (4 oz.). 

Carbohydrate. — Carbohydrates being palatable and of 
great variety, are extensively used in all fattening cures except 
where there is diabetes present or some form of carbohydrate 
indigestion. People differ both as individuals and as races 
in their ability to take carbohydrates. The average diet in 
health contains somewhere about 180 gm. (6 oz.) carbohy- 
drate per diem and if a little care is taken in selecting the 
more concentrated forms as much as 320 gm. (10% oz.) 
can easily be given patients. This additional 140 gm. (4% 
oz.) represents 570 calories. It is possible in selected cases 
and with care to increase this allowance up to 400 to 500 gm. 
The result of this one-sided carbohydrate diet is much the 
same as the excessive protein diet, i. e., the excess fat or 
excess protein stored up does not last but when the large 
amount of carbohydrate is stopped the weight rapidly de- 
clines, hence von Noorden advises against giving more than 
300 to 320 gm. (10 or n oz.) carbohydrate per diem with 
the one exception that patients who can take grape-juice 
can secure an additional 550 calories in a bottle containing 
750 c.c. (25 oz.). 

Cereal with cream, represents a good way to get in extra 
calories, and grapenuts are especially recommended by von 
Noorden, who estimates that 40 gm. (1^ oz.) of grapenuts 



DIET FOR LEANNESS OR FATTENING CURES 517 

moistened with hot water and 40 gm. (iV£ oz.) of butter 
added, served with 60 c.c. (2 oz.) of 40 per cent, cream re- 
presents about 660 calories. 

If we wish especially to increase the protein of the body the 
giving of large amounts of carbohydrate is essential, as it 
spares the protein combustion. The following list of foods 
contain 100 gm. (33^ oz.) of carbohydrate, besides other 
food elements and forms a convenient method of making 
additions to the diet. Each 100 gm. of carbohydrate re- 
presents 410 calories. 

Oatmeal, 150 gm. (5 oz.). 

Cornmeal, 140 gm. (4% oz.). 

Rice, 130 gm. (4^ oz.). 

Macaroni, 135 gm. (4^ oz.). 

Bread, 180 to 200 gm. (6 or 6% oz.). 

Zweiback biscuits, 120 to 135 gm. (4 to 4}^ oz.). 

Potatoes, 600 gm. (20 oz.). 

Sugar, 100 gm. (3^ oz.). 

Honey, 140 gm. (4^3 oz.). 

Peas (dry, 200 gm. (6% oz.). 

Fresh fruit, 1000 gm. (303^ oz.). 

Chesnuts (without shell), 130 to 140 gm. (4^ or 4% oz.). 

Grape juice, 500 to 600 gm. (16% to 20 oz.). 

Beer, 1800 to 2000 gm. (60 oz.). 
Fat. — This is the most readily available source of energy 
and represents the highest caloric value in the smallest bulk. 
People who need a fattening cure are usually poor fat eaters, 
else they would probably not be in need of fattening, for as a 
rule they do not spontaneously take over 100 gm. (33^ oz.) 
of fat per diem. With care this can usually be raised to a 
total of 250 gm. (8 oz.) of fat which alone represents 2350 
calories. It is possible at times to give even more than this, 
but as a rule this is sufficient. As a matter of fact the fatten- 
ing cure is really a process of education in the eating of fat 
for these people, as otherwise they are quite likely to relapse 
and the success of the "cure" both immediate and remote 
largely depends on the physician's ability to accomplish 
this. When gastro-intestinal disturbances are at the bot- 
tom of the nutritional disturbance it is more difficult to use 
fats in such quantities. 

Bacon, cream, butter and milk are all fat-containing foods 
of great availability and should form a large part of a fatten- 
ing cure diet. Olive oil or peanut oil are also valuable 
fatteners. 

Alcohol. — The use of alcohol as a routine in fattening cures 
is not to be recommended, as many people are better without 



518 DISTURBANCES OF NORMAL METABOLISM 

any on one ground or another, and everyone is injured by 
larger doses. Alcohol never becomes a part of the organism 
but has a fuel value of 7 calories per gm. "When 9.3 gm. 
alcohol are given 7 gm. less of fat are oxidized than would 
have been the case if no alcohol had been administered." 
Its toxic properties, as already indicated, preclude its ex- 
tensive use, although theoretically it should be a good fat- 
tening substance. Probably the best wines to use are those 
containing 15 to 20 per cent, of alcohol) — Madeira, sherry 
and port which may be allowed in amounts of 50 c.c. (1% 
oz.) at one or two meals or heavy beer or ale may be substi- 
tuted occasionally, if it can be obtained. 

The inclusion of prolonged rest in bed as a routine in fatten- 
ing cures, is not necessary but in certain cases of nervous 
exhaustion, and digestive disorders accompanied by leanness 
it is certainly indicated. In other cases it may be valuable 
as a preliminary measure but only for a short time, as active 
bodily exercise is essential if one wishes to build up not only 
fat but also muscle and leave the patient at the end of the 
cure an efficient machine and not a Strassburg goose. 

To recapitulate the suggestions for diet in leanness, it is 
recommended to construct a dietary containing — protein, 
100 to 120 gm. (31^ or 4 oz.) ; carbohydrate, 300 to 350 gm. 
(10 to 11% oz.); fat, up to 250 gm. (8H oz.). 

Alcohol if used at all 50 to 100 gm. as a 15 percent, wine. 

The procedure is to add a certain excess of food to the 
maintenance diet and gradually to increase it as the patient 
is educated up to taking larger amounts of food, as for the 
most part patients in need of fattening are those who are 
either naturally very small eaters or who have become so 
from one or another reason. 

When the rest cure plus the fattening process is to be com- 
bined, Weir Mitchell's plan is of the greatest use in properly 
selected cases where leanness is complicated by neurasthenia 
or severe gastro-intestinal disturbances (q. v.). 

PHOSPHATURIA. 

The occurrence of a cloudy urine due to the precipitation of 
phosphates is of common occurrence and has received prob- 
ably more attention than its significance warrants, due no 
doubt to the fact that when noted by introspective or neuras- 
thenic persons it has caused great mental disturbance 
regardless of a symptomatology; other people letting its 
presence pass either unnoticed or at least without anxiety. 

Phosphaturia is due to a spontaneous separation of the 
earthy phosphates, i. e., calcium and magnesium phosphates 



PHOSPHATURIA 519 

of the urine and is liable to occur in any urine which is con- 
centrated and neutral or particularly alkaline in reaction. 
This does not mean that the separation of the phosphates 
denotes a pathological increase in their excretion, for as 
Herter 1 says "it is difficult to say what constitutes an exces- 
sive excretion of earthy phosphates but at all events in most 
cases of phosphaturia there is no evidence of such excess," 
and the chief pathological significance of its separation is the 
neutral state of the urine that permits it. In other words, 
the turbidity of the urine when due to phosphates is often 
wrongly thought to be caused by an increased elimination 
(phosphaturia), while it is more likely caused by a decreased 
acidity of the urine and should be called an alkalinurea. 

"The average excretion of P 2 is i to 5 gm. per diem and 
comes in small part from the oxidation of the phosphorus of 
protein material, i. e., endogenous, and to a greater extent 
from the phosphates of the food, i. e., exogenous. The ex- 
tent to which this latter controls the phosphate excretion in 
the urine depends upon the relative abundance of alkali and 
alkaline earthy phosphates." 2 The phosphates of the alkali 
earths are absorbed with difficulty and are therefore for the 
most part eliminated directly through the feces. 

Newberg 3 classifies phosphaturia as follows: 

Physiological Phosphaturia.. — A diet rich in alkaline car- 
bonates or one which has an excess of salts of vegetable acids 
or alkaline albuminates leads to diminished urinary acidity. 
This often is found in healthy people taking large amounts of 
vegetables or alkalies (often seen during alkaline treatment 
for gout or gastric hyperacidity), or a diet rich in lime and 
magnesia may act in the same way as one containing alkali, 
all producing a phosphaturia. It may also occur physio- 
logically in an increased urinary alkalinity due to decreased 
excretion of acids in the urine. This is seen when on a diet 
that is largely protein where acid is withdrawn from the 
system to form the hydrochloric acid of the gastric juice so 
it will often be found in cases of hyperchlorhydria and gastric 
hypersecretion for the same reason. 

Nervous and Sexual Phosphaturia. — This is ascribed vari- 
ously as the cause or effect of nervous states, nervous causes 
effecting the secretory functions of the kidney and its select- 
ive action resulting in a phosphaturia. Phosphatic diabetes 
is also of nervous origin which together with essential phos- 
phaturia is included under the neurasthenic variety. 

1 Chem. Pathology, p. 127. 
2 Myers and Fine: Essence of Path. Chem., p. 32. 
2 Von Noorden: Metabolism and Practical Medicine. 



520 DISTURBANCES OF NORMAL METABOLISM 

Juvenile Type. — This is at times a nervous affair and at 
others a real anomaly of phosphaturia as proven by metab- 
olism experiments by Soetbeer, depending presumably on a 
disturbance of secretion of the mucous membrane of the 
large intestine and is often associated with calcium carbon- 
ate in the urine, called calcuria. Other cases are found 
without the associated calcuria. 

Finally disturbances of phosphorus and calcium metab- 
olism as in rickets, osteomalacia and functional disturbances 
of the sexual organs and of the thyroid also act to bring about 
a phosphaturia. 

From what has been said it can be seen that so far as we 
know phosphaturia is of comparatively slight clinical import- 
ance and should concern us as dietitians but mildly, i. e. t 
in its being responsible for any general symptomatology. 
We do know that it is increased by a diet of potatoes, fruit 
and all fresh green vegetables, as already indicated, and de- 
creased by abstaining from these articles of food, giving 
largely milk, eggs, cheese, cereals and legumes. 1 

When there have been symptoms caused by the calcuria, 
as in Soetbeer's type, limiting the articles rich in lime, brings 
the calcuria promptly down to normal. Directly trying to 
increase the urinary acidity by food or giving inorganic or 
organic acids has proven practically valueless, 2 although ben- 
zoic acid enjoys some reputation for this, it cannot be kept 
up indefinitely on account of consequent digestive disturb- 
ances. 

The presence of phosphorus in the body tissues led to giving 
foods rich in phosphorus in conditions of phosphaturia think- 
ing that this represented an excessive loss of phosphate 
from the system particularly in nervous disease, but it was 
found that the insoluble phosphates of the food were excreted 
by the feces and the soluble phosphates by the urine and any- 
how as a regular thing in a mixed diet we take in more phos- 
phates than we need to replenish those lost in the body's 
metabolism. 

Phosphates and Calculi. — One additional factor relative 
to phosphates in the urine must be considered and this is in 
connection with the formation of calculi. This occurs in the 
presence of ammoniacal fermentation of the urine in the 
bladder, during which process phosphates may be precipi- 
tated on uratic stones or the phosphates and carbonates of 
lime may be found together. 

1 Friedenwald and Ruhrah: Dietetics, p. 454. 

2 Minkouski, Von Leyden: Handb. d. ernahrungs Therap. 2d auf, 1904, p. 319. 



OXALURIA 521 

In a combination of a series of cases of 223 calculi, 36 or 16 
per cent, were phosphatic. 72, or 37 per cent, were oxalate 
of Hme often mixed with urates. 

Phosphaturia, however, is not to be confused with the 
deposition of triple phosphates from an alkaline fermenta- 
tion of the urine. 1 

Diet Recommended for Calculi. — The object is to render 
the urine as acid as possible in the hope that phosphatic cal- 
culi will be dissolved, and to this end Tibbies recommends 
tartaric and citric acids and fruits containing these and ben- 
zoic acid, such as is contained in lemons, limes, grapefruit, 
oranges, gooseberries, strawberries, currants, cherries, grapes, 
plums, green gages, etc. 2 

The dietetic treatment of stone, however, is more of a 
theoretical possibility than a clinical probability and the 
most that can be done after the removal of the calculi from 
the bladder is to combat the vesical catarrh and make the 
attempt to keep the urine acid by the means suggested but 
without very definite hope of success. 

OXALURIA. 

Calcium oxalate is the form in which oxalic acid appears in 
the urine, the oxalic acid coming from the decomposition of 
oxaluricacid, combines with calcium to form the oxalate of 
lime crystals. When there is gastric indigestion, particu- 
larly of the subacid type with the overproduction of mucus, 
oxalates are apt to be found. Also, the ingestion of certain 
vegetables, such as rhubarb, tomatoes, sorrel, cabbage, celery, 
grapes, currants, strawberries, gooseberries, plums, rasp- 
berries, cranberries, apples, pears, figs, pepper, cocoa, tea, 
coffee, if in large amounts, will result in oxaluria. Again, 
when too much wine or champagne, moselle, beer or ale are 
taken, the same result is often seen. Consumption of citrous 
fruits is also a source of oxaluria, and if much more food is 
eaten than is required by the organism. 

The real significance of the oxalates is in their relation to 
"stone" either in the kidney or bladder, which is apt to occur 
when there is an overproduction of mucus in the bladder in 
the presence of calcium oxalate crystals. 

Diet in Oxaluria. — When uch moxalate of lime is found in 
the urine it is necessary to put the patient on a thorough, 
sensible hygienic regimen, ordering only the simplest food, 
free of the substances known to contain an excess of oxalates, 
as already detailed; to avoid overfeeding and overdrinking 

1 Osier's Mod. Med. 2 Tibbies: Food in Health and Disease, p. 404. 



522 DISTURBANCES OF NORMAL METABOLISM 

and in fact doing anything to disturb digestion, which should 
be the chief care. A vegetarian diet if in muse ust be changed 
to a mixed diet and the protein ration kept at a medium high 
amount, i. e., about ioo to 120 gm. (3^ or 4 oz.). Where 
the patient is also gouty, the purine bodies should be kept at 
the lowest possible level and the total protein is better for 
being mininimal amount. In fact it is necessary to keep 
in mind all concomitant digestive or metabolic disturbances 
and construct as nearly a perfect diet as possible. 
According to Klemperer it is wise to keep foods rich in cal- 
cium at a low level — among these milk holds chief place, but 
according to Johnston-Lavis 1 there is sufficient lime even in 
a restricted calcium diet to furnish calcium for the oxalic acid 
in necessary amount for combination, so that it is not impera- 
tive that we should be so careful of the calcium intake, as an 
excess above the small amount required to form calcium 
oxalate does no particular harm. 

Mineral Springs. — The Spa treatment for oxaluria at one 
of the European resorts offers certain advantages, as here the 
patients are on a guarded dietary, live according to rule, 
exercise regularly and drink the waters probably with much 
the same effect as they would if they lived the same hygienic 
life and drank rain water. Vittel water enjoys the highest 
reputation for this particular metabolic disturbance; Con- 
trexeville coming next. In America, Saratoga and Hot 
Springs, Va., draw a fair number of persons needing Spa 
treatment. 

DIET IN OLD AGE. 

Much has been written on the dietetics of old age and it 
seems a pity that so many people as they grow older do not 
take the trouble to consult their physicians about a diet, for 
it is certainly a rare occurrence to have an elderly patient 
come for advice in this, unless there are some symptoms 
pointing to disease for which the patient thinks he should 
have a diet. It is unquestionably true that more damage is 
done by these people by overeating than by any other form 
of excess, for illnesses which might run a favorable course 
are prone to terminate fatally in the habitually overfed indi- 
vidual of advanced years. Among the conditions especially 
unfavorably influenced by either obesity or excessive eating 
in the aged are chronic cardiovascular disease, chronic 
emphysema and bronchitis, chronic nephritis and hyper- 
tension, and he that would live to an advanced age must be 
free of all unnecessary handicaps. 

1 Brit. Med. Jour., 191 1, p. 966. 



DIET IN OLD AGE 523 

The natural tendency of elderly people is gradually to cur- 
tail the quantity of their food and to simplify its quality, for 
a person reaching old age has gotten there, to some extent at 
least, by a life of more or less abstemious living, so that the 
rational sequence of events is, for such an one to live more and 
more simply. The exceptions to this while numerous, of 
course, only tend to emphasize the rule already stated. In 
nothing is this curtailment better seen than in the modern 
tendency to reduce the intake of animal protein, especially 
meat. This is no doubt the result of constant reiteration on 
the part of many physicians, the newspapers, magazine 
articles, etc., and while it has its good side, it is not at all 
certain that the entire withdrawal of meat is advantageous 
in an elderly person otherwise healthy. Many of the most 
famous nonagenarians and a few centenarians have taken 
meat daily during the entire time and we have seen that the 
consensus of opinion is that a vegetarian diet does not tend 
to good resistance to disease, but rather the opposite. Conari 
who lived to be a hundred and wrote a treatise on longevity, 
was a mixed feeder, taking a considerable proportion of his 
daily ration in meat of various sorts, eating about 12 ounces 
of food daily made up chiefly of bread, wine, broth, eggs, 
veal, mutton, partridge, chicken, pigeon and fish. When 
disease of the kidneys and bloodvessels is prominent it is a 
different matter and meat must here be reduced below that 
allowable for the ordinarily healthy old person. 

The reduction usually seen in the diet of old people is 
secondary, of course, to a general diminution in their digest- 
ive powers, both secretory and motor, for in many old people 
the free HC1 and pepsin are either absent or much dimin- 
ished and probably to some extent accounts for the lessened 
appetite for meat. The stomach and intestine tend to 
greater dilatation and lessened peristalsis, in many cases 
there is constipation and in some undue absorption of digest- 
ive by-products, so that they soon learn that too much food 
favors the accumulation of waste. Metchnikoff sums up 
the pathology of old age as a " sclerosis affecting all the or- 
gans but especially the bloodvessels." 

Food Requirements of the Aged. — When we come to study 
the actual food requirements of the aged we find practical 
unanimity in the lessened amount of food needed to furnish 
energy for these people, the actual amount in a given case 
depending on the person's activities. 

Murel 1 emstiates the maintenance diet of old people as 
follows : 

1 Rev. Soc. Science Hyg. Aliment, 1906, p. 763. 



524 DISTURBANCES OF NORMAL METABOLISM 

Age. Protein per kilo. Energy per kilo. 

Adult i . 50 gm. 35 to 38 calories 

50 to 70 years 1.25 " 30 to 35 

70 years and over 1.00 " 25 to 30 " 

Extreme old age 0.75 " 20 to 25 " 

These estimations are for people at rest, not at work. 
When one studies the relative values of food requirements 
for persons of different age and occupation, as compared 
with that required by a man in full vigor at moderate work, 
the same diminution is seen in the requirements for old age. 1 

Man, period of full vigor at moderate work . . . . =100 gm. protein 

" hard work = 120 

" sedentary occupation . =80 

Woman, period of full vigor at moderate work ... =80 

" sedentary occupation . = 70 

Man or woman at hard work =100 " 

old age - . . =90 " 

extreme old age = 70 to 80 " 

Boy, fifteen or sixteen years old =90 " 

thirteen or fourteen years old =80 

twelve years old =70 " 

" ten to twelve years old =60 

Girl, fifteen or sixteen years old =80 

" thirteen or fourteen years old =70 

ten to twelve years old =60 

Child, six to nine years old - . . =50 

two to five years old =40 

under two years old =30 

So, too, when one investigates the actual dietaries used by 
old people, they will be seen to conform very largely to these 
figures. Thus, for example, Forster found that among a 
number of elderly people the following figures applied: 2 

Protein. Fat. Carohbydrates. Calories. 

Men ....... 92 45 332 2149 

Women 80 49 260 1875 

There is no doubt but that metabolism proceeds at a much 
slower pace in old age than earlier, and the food requirements 
are less, both in so far as nitrogenous food is concerned as 
well as in the total energy requirement, and in practice one 
constantly sees old people living on a diet which would be 
hopelessly inadequate in both, particularly for a younger 
person of the same weight and height, nevertheless main- 
taining weight and vigor in a normal degree. 

Just what part the internal glandular secretions have to do 
with this is not clear but presumably the lessened thyroid 
secretion in old age accounts to some extent for the lessen- 
ing of metabolism. 

1 Langworthy: Year Book of Department of Agriculture (U. S. A.), 1907. 
2 Hutchinson: Food and Dietetics, p. 46. 



DIET IN OLD AGE 525 

Gurier 1 following the metabolism of five old people con- 
cluded : 

1. That the amount of protein consumed by old men may 
be diminished if considerable fat and carbohydrate is given 
to replace it. 

2. The assimilation of nitrogen by old men is less than 
normal, in these instances varying between 86.17 and 91.15 
per cent; that of young men on similar diet being 94 per 
cent, and it made little difference whether the nitrogen was 
furnished in meat and milk or beef tea and vegetables. 

Sonden and Tigerstedt 2 found by metabolism experiments 
that, as measured by the respiration apparatus, old men and 
women excreted a less amount of C0 2 per square meter of 
surface area than young or middle-aged people. There was 
practically no difference in the C0 2 excretion of the two sexes, 
which is contrary to that which is found in those of younger 
years, where in men the CO 2 excretion is greater than in 
women of the same surface area. 

Since the lessened food requirements are thoroughly 
demonstrated the only question that arises is where the 
greatest reduction should be made. 

The fact that the natural tendency for old people is to eat 
less of meat, the frequent absence or diminution of HC1 and 
pepsin in the gastric secretion already alluded to, makes it 
quite evident that the curtailment should be largely in this 
direction. Some authorities going so far as to say that no 
large meat eaters live to a great age. The low physiological 
requirements of nitrogen as determined by Chittenden 3 are 
certainly applicable here and should be adhered to or at 
least not greatly exceeded (roughly 45 to 65 gm. protein per 
day), as giving the kidneys less excretory work, while the 
larger bulk of the diet can be made up of carbohydrates and 
fats. 

Foods Especially Desirable for the Aged. — Sir Henry 
Thompson wrote that "indigestion was not a disease but an 
admonition," so that when one suffers from indigestion it 
proves that one has not yet found one's ideal diet and at no age 
is this more true than in old age, where great care is neces- 
sary to avoid the disastrous results of gross dietary indis- 
cretions, which with a weakened heart or bloodvessels might 
very well be serious. 

According to the same eminent authority, half the chronic 
diseases seen in advancing years are due to dietetic errors, a 
large portion of which might by care be easily avoided. 

Nibbles: Food in Health and Disease, p. 175. 
2 Skand: Arch. Physiol., 1895. p. 1. 
3 Physiol. Economy in Nutrition. 



526 DISTURBANCES OF NORMAL METABOLISM 

Animal Food for the Aged. 1 

Tender chicken, game or meats. 

Potted chicken and sweetbreads. 

White-meated fish, flounders, sole, smelts, halibut, cod. 

Bacon, grilled; eggs, lightly cooked or beaten up with 

milk. 
Nutritious soups, chicken puree, fish puree, beef tea, 

mutton, or chicken broth. 
A I ilk in all forms when well digested. 
Milk and Vichy. 
Vegetable Foods for the Aged: 
Smooth bread and milk. 
Cereals. 

Puddings of ground rice, tapioca, arrowroot, sago, maca- 
roni with milk and eggs served with a little jelly. 
Stale bread and butter, rusks. 
Artificial foods, predigested starches. 
Farinaceous foods should be subjected to high tempera- 
ture for a long period to break the starch granules. 
Vegetable purees of all kinds. 

Stewed or baked fruits, fruit jellies, pulp of ripe fruits. 
If fruits are too acid, neutralize with a little soda, as less 
sugar will be demanded with consequently less fermentation 
and acidity. 

Lactose is better than cane-sugar for sweetening. 
Butter, cream and oil are allowed for fats. 
Bread, whether white or brown, should be toasted quite 
brittle, the amount for a meal, 3 to 5 ounces when fresh, then 
toasted. Fresh butter, 3 or 4 ounces. 

Weak tea is best for breakfast with considerable milk, 
sugar if it agrees, taken five minutes after the meal, not with 
it, and he is very insistant that no liquid should be taken 
with meals, but directly afterward and between. 

He recommends two hours of quiet sedentary occupation 
after breakfast, then an hour or more of exercise with a little 
rest. Rest twenty to thirty minutes before luncheon, re- 
cumbent. One and a half hours' rest after luncheon, then 
a drive, visit, whist, billiards or light exercise. 

A cup of tea at five, without food. A light evening meal 
at 7 p.m. without meat or rich foods of any kind. 

This list agrees well with the general consensus of opinion 
and it will be seen from it that meat is by no means forbid- 
den. It should preferably be used but once a day, best at 
the midday meal, but unless there is some contra-indication 
as gout or hypertensive nephritis, it need not be excluded. 

1 Yeo: Food in Health and Disease, p. 287. 



DIET IN OLD AGE 527 

It must be borne in mind that elderly people cannot be 
starved to any greater advantage than other people and on 
the other hand at no time in life should greater care be taken 
to prevent overfeeding. For the most part the appetite 
must be trusted, as few old people will voluntarily agree to 
diet according to a specific weighed quantity of food, but 
where this is seen to be excessive and particularly in the 
direction of protein food a definite menu should be written 
out giving particular amounts of each article to be taken at a 
meal. 

Preparation of Food for the Aged. — Since with advancing 
years the teeth are apt to be gradually eliminated, the proper 
preparation of food becomes of increasing importance, cer- 
tain authorities point to this loss of teeth as a physiological 
process and say that it is a mistake to replace them by arti- 
ficial teeth, as their wearers are apt to overeat and that their 
loss is Nature's way of curtailing the intake or at least of 
necessitating its soft consistency. 

On the other hand, it is a fact that most teeth in advancing 
years are lost through infection and decay which would not 
occur if we lived on a rational dietary requiring much more 
chewing and that in the aged among savages the teeth may 
be worn down to stumps, but are seldom missing. Never- 
theless, we are confronted by the undoubted fact that in the 
majority of cases the teeth of old people are either wanting 
or are at least in poor condition for fulfilling their normal 
function, so that we have the alternative of either supplying 
artificial teeth or giving food that does not need any chewing. 
There can be little doubt but that making good the defi- 
ciency by artificial teeth is the correct procedure with due 
care in the preparation of food, and improvement in diges- 
tion is often dated from the time that people secure adequate 
means of chewing their food. 

Food should be prepared without too much of a rough ele- 
ment in the form of connective tissue and cellulose, so that 
meats should be tender and well cut up before eating and 
vegetables thoroughly cooked or divided. 

The starch foods should be thoroughly cooked in order to 
break the cellulose envelope of the starch grain. This also 
applies to vegetables, although with good teeth there is no 
objection to soft raw fruits, and salads, if not rich. It is 
also necessary to guard against taking large quantities of 
animal fat with a high melting-point, such as mutton fat, 
which often causes digestive disturbance by its overslow 
disintegration. With these few precautions it is not neces- 
sary to soften the food for elderly people except in extreme 



£28 DISTURBANCES OF NORMAL METABOLISM 

old age; however, where the muscular power to chew satis- 
factorily is lacking the food should all be thoroughly softened 
and the individual urged to slow insalivation. 

Diet Routine in Old Age. — Sir Henry Thompson 1 in his 
classical monograph recommends four meals a day for the 
aged. Breakfast at 8.30 a.m., luncheon 1.15 p.m., dinner at 
7 to 7.30 p.m., and a light supper at 11.00 km. in the follow- 
ing manner. 

"The animal foods supplied for breakfast and at lunch 
may include eggs or fish cooked in various ways. At lunch- 
eon a little tender meat or fowl may be taken, unless it is 
preferred to reserve them for dinner, in which case fish and 
farinaceous pudding may be substituted. This last-named 
meal should generally commence with a little good con- 
somme ; often substituting a vegetable puree, varying with 
the season and made with light meat stock or broth ; or a 
good fish soup as a change. Then a little fowl or game and 
a dish of vegetables, according to the time of year. Finally, 
perhaps, some light farinaceous pudding with or without 
fruit, should close the meal, which is to be a light one in re- 
gard to quantity. 

" Lastly, supper; a very light refreshment may be advan- 
tageously taken the very last thing before entering bed, at 
about eleven o'clock or so, as it favors sleep. Elderly men 
require some easily digested food to support them during the 
long fast of night. It is well-known that the forces of the 
body are at their minimum at 4 or 5 a.m. and this may be 
well provided for by taking about 5 or 6 ounces of consomme 
with one ounce of thin toasted bread, served in the bedroom. " 

The question of the use of alcoholic beverages often comes 
up for consideration in connection with the diet of the aged 
and needs a word of explanation. Probably no good is done 
by their use that might not be better done by other means, 
e. g., food, hot milk, hot tea, etc., so that it is never necessary 
to recommend alcohol for the aged, although when chilled 
on coming into the house and when it is not possible for one 
to go to bed with hot-water bottles, etc., a drink of diluted 
spirits taken hot induces capillary dilatation, diaphoresis 
and often relieves an internal congestion better than by other 
means. Aside from this, the aged are better without alco- 
hol. If, on the other hand, they insist upon it, the best 
form is a claret or white wine diluted with alkaline water or 
a very little whiskey or brandy taken in the same way. 

It is not necessary or worth while to set down sample diet- 
aries for old people, as no two people would probably want 

1 Diet in Relation to Age Activity. 



OSTEOMALACIA 529 

the same assortment of foods, old age being famous for insist- 
ing on individual likings, but with the foregoing explanation 
and suggestions in mind anyone can construct a diet suit- 
able for an elderly person. Fletcher's Dietary Routine is 
certainly valuable for many elderly persons, (see p. 649). 

OSTEOMALACIA. 

Since in this disease the bones undergo softening due to a 
disturbed calcium and phosphorus metabolism it would seem 
as if feeding foods rich in these substances or even giving 
them in medicinal does would be a rational procedure. As 
a matter of fact while this may be tried and is usually done, 
the fault lies in an excessive excretion of these substances 
rather than to the fact that the diet does not contain suffi- 
cient for metabolic needs, so that it is much like trying to fill 
with water a barrel that has several holes in the bottom. At 
the same time since the output of these elements is excessive 
unless we add a certain surplus in the diet, the system be- 
comes more or less completely drained of calcium and phos- 
phorus; in other words, we can keep the barrel partly full 
of water by pouring in at the top in spite of a leaky bottom. 

To this end we can give the calcium-containing foods, 
such as milk, oatmeal, green vegetables and fruits, while to 
help in replacing the phosphorus loss, fish and cod-liver oil 
are very good. 

Adrenalin by injections or fed by mouth seems to do good 
in certain cases, probably by means of its effect on meta- 
bolism. If all other means fail and as a procedure of last 
resort castration may be done, which results in a retention 
of calcium and phosphorus in the system from a changed 
body metabolism. 



34 



CHAPTER XXVII. 
DIET IN THE BLOOD DISEASES. 

THE ANEMIAS. 

The relation of diet to diseases of the hemapoietic system 
must, of course, in the very nature of things, be an intimate 
one. Nevertheless, although this is so. comparatively little 
is known about the etiology of the diseases characterized 
by marked blood changes nor how diet might modify them, 
except to a minor degree. That malnutrition, from what- 
ever cause, is accompanied by a greater or less degree of 
anemia is common knowledge and these changes may be 
qualitative as well as quantitative. 

Toxemia is a convenient phrase to cover our ignorance 
and while doing so, it is more than likely at the bottom of 
much of the so-called primary anemia, and secondary as 
well; in fact all anemias must be secondary, but when the 
probable cause is too elusive, it is easier perhaps in the pres- 
ent state of our lack of knowledge to distinguish between 
primary of unknown origin and secondary of known origin, 
or better, whose chief accompanying condition of disease is 
recognized. Of the simple primary anemias, chlorosis is 
the chief example; those primary cases which are severe 
and often fatal with still greater differences between their 
blood picture and that of normal blood are called pernicious 
anemia. In both forms of primary anemia there are marked 
changes in blood production as well as destruction. In the 
secondary anemia, while we are able to tell the accompany- 
ing condition which is doubtless responsible for the anemia, 
we do not know how it acts to bring about blood destruction, 
for in secondary anemia there is apparently little interfer- 
ence or change in the blood-forming functions, but the agen- 
cies that destroy the blood are all important and keep the 
patients anemic until conditions are changed or causes re- 
moved. Chlorosis or " green sickness" occurs for the most 
part in young girls, often without apparent cause, but is 
very apt to show itself at puberty or when a complete 
change is made in residence or work, as in the case of young 
immigrants. Of the dietary cases we find that many chlor- 
otics eat a very small amount of protein and fat and too 
much carbohydrate, or the total amount of food is too 
small. In other cases the diet contains too large a propor- 

530 



THE ANEMIAS 531 

tion of foods that are actually injurious, such as vinegar, 
coffee, tea, highly spiced or seasoned food. 1 

The habit of taking large amounts of tea, while not a 
proven etiological factor, is so frequently an associated con- 
dition that the suspicion seems justified that there is definite 
connection between the two. In these cases there is very 
apt to be found more or less tissue hydremia, as shown by 
subcutaneous edema, and when present in marked degree, 
even in the absence of any direct renal complication, special 
salt-poor dietetic rules apply. There is little difficulty in 
making the diagnosis of chlorosis in a typical case or even 
when complicated by edema, but when as often happens, 
there are marked gastric symptoms, one is often at a loss to 
know whether the case is one of simple anemia or of peptic 
ulcer with a complicating anemia, for ulcer symptoms may 
be more or less exactly simulated. The author has in mind 
one case which was treated for ulcer by two dietary cures 
without relief to the pain, which promptly disappeared, 
followed by complete recovery when iron was given. Just 
what the association is between the anemia and symptoms 
of ulcer it is not possible to say, but it is quite usual to find 
a hyperchlorhydria in chlorotics which by causing pyloro- 
spasm may give rise to the pain. Whatever the cause the 
facts are important enough to be kept in mind. 

Treatment of Chlorosis. — In considering the treatment of 
chlorosis one must take into consideration the following 
recommendations, all of which are important. 

1. Rest, and rest in bed for severe cases. 

2. Treatment for gastro-enteric associated conditions, 
notably constipation. 

3. The giving of iron in some form. 

4. Diet. 

While this volume has little to do with general treatment of 
disease there are certain conditions in which diet plays in 
some respects a minor role, except it be a part of a general 
plan of attack, and chlorosis belongs to this class. 

Rest. — There are many cases of obstinate chlorosis and 
secondary anemia, which in spite of every other means do 
not progress satisfactorily unless complete rest is added to 
the regimen. This means rest in bed and in the fresh air 
and sunshine as much as possible. This procedure alone is 
capable of changing the result to a successful issue. 

The treatment of gastro-intestinal conditions is exceed- 
ingly important and in certain cases accompanied by marked 
constipation, the relief of this complication by appropriate 

3 Sutherland: System of Diet. p. 627. 



532 DIET IN THE BLOOD DISEASES 

diet see section on Constipation, p. 397) often results in a 
disappearance of the anemia. Where there are symptoms of 
so-called toxic absorption, such as headache, asthenia with 
or without marked urinary evidences of intestinal putrefac- 
tion (e. g., increased ethereal sulphates and indicanuria), 
high colon irrigations plus a laxative diet are exceedingly 
valuable measures and may alone solve the problem. 

Iron. — In practically every case of simple or secondary 
anemia the giving of iron in some form is to be considered 
and leads naturally to the question of iron metabolism. 
Much time and investigation has been expended on this 
question and even yet there is no unanimity of opinion as 
to just how it acts in restoring the blood elements to their 
normal condition. From the theoretical stand-point a full 
mixed diet contains sufficient iron, in organic combination, 
to satisfy the demands of the system, but whatever the per- 
version of metabolism, the time comes when the destruction 
of blood proceeds more rapidly than its regeneration and the 
organism is no longer able to make use of the natural food 
iron in sufficient quantity or sufficiently rapidly to preserve 
the normal balance, and anemia results. 

Theories of the Action of Iron. — There are at least three 
chief theories of the action of iron : 

1. That the system can make direct use of inorganic iron 
as such but in exceedingly small quantities, which is either 
directly absorbed or acts as a stimulant to the hemapoietic 
organs. 

2. That the body can only make use of organic iron in one 
or the other of these ways. 

3. That either organic or inorganic iron furnishes an ele- 
ment to the intestinal contents which prevents the destruc- 
tion of the normal food iron albuminate and releases it, so 
to speak, for its proper use in blood building. 

Austin 1 says "from the work of Abderhalden, Muller and 
Tartakousky it seems probable that iron in the organic form 
as an albuminate of iron may be absorbed and utilized for 
hemoglobin formation, but that in this form it is no more 
effective, but probably less effective than is the iron which is 
a natural constituent of such foods as lima beans, peas, spin- 
ach, red meat, yolk of eggs, etc. " He also doubts that inor- 
ganic iron stimulates the blood-forming organs^ although a 
true stimulation of these organs may in certain instances be 
possible. 

The iron in the blood is found as hemoglobin and the total 
amount of iron in the blood of an adult is 3 gm. 2 

1 Therap. Gaz., 1914, 3 S., xxx, 846. 

2 Tibbies: Diet in Health and Diseases, p. 81. 



THE ANEMIAS 533 

There is also much iron in the liver and spleen which exists 
in the liver as compounds of iron with nuclein and protein. 
After the exhibition of inorganic iron all but a very small 
part appears in the feces. 

For the percentages of iron in different foods see p. 96. 

Diet in Chlorosis. — In choosing foods especially good for 
chlorosis one should, theoretically at least, take those forms 
which are highest in natural iron compounds, although of 
course it is not practicable to confine the diet exclusively to 
these articles. All foods should be fresh, not cooked over, 
salted, tinned or dried. 

When there are gastro-intestinal symptoms it is best to 
put these patients on a fluid or semifluid diet until the symp- 
toms subside and then to increase to a light diet and finally 
to a full diet somewhat as follows, as outlined by Sutherland 1 
choosing largely from the iron-rich foods. 

Diets in Anemia (Chlorosis): 

4.00 a.m. Milk, 300 c.c. (10 oz.). (Hot or cold.) 
8.00 A.M. Bread and milk, 450 c.c. (15 oz.). 
11.00 a.m. Egg flip, 300 c.c. (10 oz.). 
1. 00 p.m. Milk pudding with milk, 450 c.c. (15 oz.); 

(corn flour, ground rice, seminola, sago, 

tapioca, arrowroot custard). 
3.00 p.m. Benger's food, 300 c.c. (10 oz.) or malted milk. 
5.30 p.m. Milk pudding or bread and milk, 300 c.c. 

(10 oz.). 
8.00 p.m. Milk, 300 c.c. (10 oz.). 

Light Diet. 

4.00 a.m. Milk, 300 c.c. (10 oz.). 

8.00 a.m. Milk or weak tea with milk, 300 c.c. (10 oz.) ; 

bread and butter, 60 gm. (2 oz.) ; white 

fish, boiled, with white sauce, 120 gm. (4 

oz.) or an egg. 
1 1. 00 a.m. Milk, Benger's food or malted milk, 300 c.c. 

(10 oz.). 
1. 00 p.m. Chicken or white soup, 300 c.c. (10 oz.); 

bread, 30 gm. (1 oz.) ; potatoes, 60 gm. 

(2 oz.); vegetables, 30 gm. (1 oz.) ; milk 

pudding, 300 c.c. (10 oz.). 
5.30 p.m. Milk or weak tea with milk, 300 c.c. (10 oz.); 

bread and butter, 60 gm. (2 oz.) ; an egg or 

white fish, 120 gm. (4 oz.). 
8.00 p.m. Milk, 300 c.c. (10 oz.); cream, 300 c.c. (10 oz. 

daily. 

1 System of Diet and Dietetics, p. 617. 



534 DIET IN THE BLOOD DISEASES 

Full Diet. 

4.00 a.m. Milk, 300 c.c. (10 oz.). 

8.00 a.m. Milk or weak tea with milk, 300 c.c, (10 oz.); 
bread and butter, 120 gm. (4 oz.); white 
fish, 120 gm. (4 oz.), or an egg. 
1 1. 00 a.m. Milk, Benger's food or malted milk, 300 c.c. 
(10 oz.). 
1. 00 p.m. Soup, 300 c.c. (10 oz.) ; meat, boiled or roasted 
180 gm. (6 oz.); bread, 60 gm. (2 oz.); 
potato, 60 gm. (2 oz.) ; milk pudding, 300 
c.c. (10 oz.). 
5.00 p.m. Milk or weak tea with milk, 300 c.c. (10 oz.) ; 
bread and butter, 120 gm. (4 oz.); an egg 
or white fish, 120 gm. (4 oz.). 
8.00 1. M. Milk, 300 c.c; (10 oz.) cream, 300 c.c. (10 
oz.) per day. 
There seems to be a general consensus of opinion that blood 
pigment is increased by a diet with a large amount of pro- 
tein; scraped beef sandwiches, meat broths thickened with 
scraped meat, giving as high as 150 to 180 gm. (5 or 6 ounces) 
of albumin in a day. See gives 14 ounces of raw meat daily. 
Green vegetables also being rich in iron are to be used in large 
amount and many think that claret, Burgundy, Madeira, 
porter and stout 1 help to increase the formation of hemoglo- 
bin. Whether this is so or not is not possible to say, but often 
such addition to the diet increases the appetite and aids 
digestion if taken in very moderate amounts. 

Von Noorden advises protein-rich food because the readily 
available carbohydrates go to the liver first and recommends 
five meals per day as follows: 

Breakfast: Two or 3 ounces (60 to 90 gm.) meat; one 
or two slices toast or unsweetened rusks; small cup 
of tea with very little cream or sugar. 
Mid- A.M.; Two eggs, toast, butter, glass of milk and a 

little sherry. 
Luncheon: Preceded by one-half hour rest, then a full 
meal, without soup, if the appetite is poor. No 
fluid with this meal. Rest afterward. 
Mid-P.M.: Cooked or raw fruit with zweiback or 
bread. If there is already too much acidity he gives 
tea, cocoa, toast followed by a glass of milk and 
cream. 
Supper: Any simple food. 
Bedtime: Beer or milk. 

1 Thompson: Practical Dietetics, p. 537. 



THE ANEMIAS 535 

When there is edema present it is necessary at times to 
limit the fluid and salt intake to the point of a salt-poor diet, 
such as is used in nephritis. The anemia in these cases is 
due to a certain extent at least to too much blood plasma and 
chloride retention. 

Secondary Anemia. — The treatment of secondary anemia 
consists in doing all one possibly can to remove the under- 
lying cause or mitigating it as much as possible if it is not 
possible to remove it, e. g., in the case of a chronic nephritis. 

The other essentials of treatment are the same as those 
already outlined for chlorosis. 

Pernicious Anemia. — Since the causes of pernicious anemia 
are not definitely known it would seem out of place in a work 
on Dietetics to spend too much time on the discussion of the 
various theories advanced. The blood picture which is 
found in cases of bothriocephalus Iatus is so precisely that of 
pernicious anemia that the finding of a hemolytic element in 
the parasite seemed to establish this form of anemia as due 
to hemolysis, and by analogy it was sought to trace cases other 
than of bothriocephalic origin to intestinal hemolysins. In 
pursuance of this theory Hopkins 1 extracted the stools in 
various diseases and tested for hemolysins with the follow- 
ing conclusions: 

1. The extract from stools of primary anemia did not 
show the presence of hemolysins with any degree of consist- 
ency. 

2. The extract from stools of renal and gastro-intestinal 
cases did show hemolysins in approximately 50 per cent, of 
the cases. 

3. Normal stools gave negative results. 

These conclusions do not bolster up the hemolysis theory 
to any satisfactory degree, at least as far as pernicious 
anemia goes. Finding the associated achylia gastrica as 
such a frequent accompaniment of pernicious anemia at 
first led to the conclusion that the gastric atrophy stood in 
a causal relation. But as the achylia and atrophy are fre- 
quently found without pernicious anemia this had to be 
given up. Friedenwald 2 after analyzing a series of cases 
concluded that "it is quite probable that the poison which 
produces the hemolysis is the same which is also responsible 
for the alteration in the gastric secretion." 

Again the spleen was thought to be concerned with the 
production of the disease or on account of its being the 
"graveyard" of the red cell the removal of the spleen was 

1 Proc. Path. Soc, Philadelphia, 19 13, xv, 46. 

2 Alumni Assn. Coll. Phys. and Surg., Baltimore, T912; 3, xv, 97. 



536 DIET IN THE BLOOD DISEASES 

practised. Some cases seemed to improve but eventually 
the disease progressed. Whatever the actual causes of 
pernicious anemia are, there is no doubt but that blood 
destruction by some means is excessive and fatal and the 
stimulation of the blood-forming organs is also great, as 
shown by the putting into the circulation great numbers of 
immature blood cells apparently in an attempt to compen- 
sate, as Nature so often does. 

In the absence of positive knowledge as to the etiology of 
pernicious anemia any attempt to prescribe a diet based on 
physiological needs is out of the question and all that one can 
do is to take cognizance of associated conditions of the ali- 
mentary canal from the teeth and gums, clear through to 
the rectum and eliminate every possible pathological condi- 
tion that is found, such as removal of bad teeth, treatment of 
pyorrhea, the use of artificial gastric juice (dilute hydro- 
chloric acid and pepsin), regular intestinal emptying with 
cathartics and high colon irrigation and in addition the use 
of duodenal lavage by allowing one or two quarts of saline to 
flow into the duodenum through a duodenal tube on a fast- 
ing stomach. This latter procedure seems to do good, but 
not unquestionably so. 

The actual diet best for pernicious anemia is more or less 
problematical and no case has been cured by it. At the same 
time it is of distinct value in keeping the patient's condition 
up to the highest point of efficiency for the particular indi- 
vidual. The food should all be nourishing and patients for- 
bidden to fill up on non-essentials; the iron-containing foods 
as in chlorosis are good but in view of the usually deficient or 
absent gastric secretion meat once a day is all that is indi- 
cated, finely cut and without connective tissue. Thompson 
recommends fresh fruit, green vegetables, oranges, lemons, 
grapefruit, apples, beans, lettuce, celery, potatoes and meat 
once daily, all with a large amount of water between meals. 
Carbohydrates are rather better borne than proteins and 
should form the bulk of the meal. On the other hand Bar- 
ker 1 recommends a meat diet at first, followed by a diet rich 
in protein urging the patients to eat regardless of appetite 
or the effect on digestion. He also recommends dilute 
hydrochloric acid shortly after meals, and pancreatin and 
calcium carbonate each 45 gr. (3 gm.) three hours later. 

Many authorities recommend very highly the feeding of 
bone marrow from the long bones of ox or sheep given in 
doses of half an ounce to an ounce and a half, spread on bread 
well-seasoned with pepper, Worcestershire or tomato sauce 

1 Johns Hopkins Bull., 1918, xxviii, 355. 



HEMOPHILIA 537 

or added to bouillon. When not possible to obtain the mar- 
row fresh, one of the preserved preparations may be used. 
Whether the use of marrow is actually favorable it is not 
possible to say but it at least cannot do harm and is worth a 
trial. 

Posthemorrhagic Anemia. — This is most often a sequence 
of some acute surgical condition which demands interference. 
When established in an acute form the indications are, of 
course, to make up the deficiency of the liquid portion of the 
blood by means of saline enemata, hypodermoclysis, intra- 
venous saline infusion or blood transfusion. These pro- 
cedures are all best when the likelihood of further hemor- 
rhage has been prevented by appropriate medical or surgical 
treatment. During convalescence the diets as suggested for 
chlorosis are recommended, giving a large amount of protein 
in the form of meat and eggs, milk and beef juice, together 
with green vegetables and fresh fruits. 

LEUKEMIA. 

From a dietetic point of view this disease is of scant import- 
ance so far as the particular foods go that might be of bene- 
fit in combating the condition, because we know nothing of 
its etiology. Presumably a mixed diet with considerable 
protein and moderate amount of carbohydrate with green 
food is best, but the time comes in many of these cases when 
the mouth and gums are in such a pitiable condition, bleeding, 
ulcerated and painful that the taking of any kind of food 
becomes a hardship and even drinking water is almost im- 
possible. Under such circumstances one may feed by gav- 
age concentrated liquid foods (see Suralimentation, p. 550). 
These may be given by putting the tube to a point below the 
larynx or by merely slipping a catheter into the back of the 
mouth and letting the food pass in slowly through a funnel, 
provided the act of deglutition is not in itself painful. When 
even this is too painful the tube may be passed to the stomach 
or nearly so, or a small catheter passed through the nose, to 
a point below the larynx and liquid food poured in. 

HEMOPHILIA. 

For a long time it was thought that a deficiency of calcium 
in the blood was at the bottom of the etiology of hemophilia, 
but the conclusion has been reached that in this disease the 
lack of calcium has nothing to do with its causation and the 
addition of calcium to the blood does not hasten clotting. 1 - 

1 Addis: Jour. Path. Bact., 1911, xv, 427. 



538 DIET IN THE BLOOD DISEASES 

Hess concludes that typical hereditary hemophilia is not 
associated with a deficiency of calcium. 1 One typical hemo- 
phyliac did show a definite calcium deficiency from a func- 
tional point of view and quantitative estimations of calcium 
in the blood showed a deficiency below the normal. 

Since some apparent benefit has followed the giving of cal- 
cium lactate to cases of hemophilia it would seem indicated 
to include in the dietary as much calcium-containing food as 
possible, such as milk, zoolak, buttermilk, cheese; in fact, 
milk in any form; oatmeal, bread and fresh herbaceous vege- 
tables. Aside from this possible indication the diet for the 
hemophiliac should be in accordance with any concomitant 
symptom, such as anemia, gastro-intestinal disturbances, 
nephritis, etc. 

PURPURA HEMORRHAGICA. 

This condition is really only a symptom and is character- 
ized by subcutaneous or submucous hemorrhages without 
known cause, although it occurs as an associated condition 
with such diseases as severe and terminal nephritis, arth- 
ritis, sepsis and profound anemia and is here presumably 
of toxic origin. 

The dietetic necessities of this disease, if there are such, 
are entirely unknown and one can do little more than regu- 
late the diet in accordance with diseases with which pur- 
pura is associated. 

1 Johns Hopkins Hosp. Bull., 1915, xxvi, 372. 






CHAPTER XXVIII. 

DEFICIENCY DISEASES. 

Deficiency diseases are those pathological states of the 
body due to a lack of certain accessory substances in the 
food called vitamines. Yitamines are of recent discovery 
and are still few in number so far as is yet known. So far as 
actually demonstrated this class includes scurvy, beriberi and 
xeropthalmia certainly, probably rickets and osteomalacia and 
possibly pellagra and sprue. Where the regular food supply 
contains these vitamines, no disturbances of this nature arise 
but if foods lacking in vitamines are fed, the subject rapidly 
develops one or another form of disease, depending on the 
vitamine that is lacking. Whether the vitamines are in- 
terchangeable is not yet known, e. g., whether a certain de- 
ficiency disease can be cured by the vitamines concerned 
with another disease entity. They probably are not inter- 
changeable. There is still comparatively little known of 
the entire subject. 1 

SCURVY. 

Scurvy is distinctly and exclusively a dietetic disease and 
is probably due very largely to the lack of vitamines in the 
food, but there is also undoubtedly an element of individual 
predisposition, for with a number of individuals under 
exactly the same conditions of diet in which the fresh food 
principles are lacking, only a certain number will contract 
scurvy. This is particularly well seen in children under a 
year old. Before antiscorbutic substances were known it 
was a very common thing to find scurvy wherever persons 
lived on a monotonous diet lacking in freshness, e. g., on 
long cruises, jails, almshouses, etc., but since the prevention 
of the disease has become so generally known the cases arise 
only sporadically in people who are on such a diet. The 
pasteurization or sterilization of milk has long been thought 
to account for many cases and there is no question but that 
they predispose to scurvy. Hess was able to produce scurvy 
in infants almost at will by putting them on a diet of pasteur- 
ized milk and to cure them promptly by antiscorbutics added 
to the diet. On the other hand, the New York Board of 
Health have about 55,000 babies to whom they yearly supply 

1 For a fuller discussion of these deficiency diseases see p. 102, Part I. 

539 



540 DEFICIENCY DISEASES 

pasteurized milk through the milk stations, and of this-, 
number only 5 developed any signs of scurvy in 19 15 (Sobel). 
This is largely due to the fact, no doubt that few of the 
mothers limit the babies' diet to milk, but after six months 
are apt to give vegetables, beef juice, soup, etc., all good 
antiscorbutics. Even breast-fed children develop scurvy at 
times. 

In metabolism experiments on a case of scurvy, Bauman 1 
found the total sulphur metabolism normal. Chlorine and 
sodium were retained during the period when fruit juice was 
added to the scorbutic diet, but excreted in excess of the 
intake during the preliminary period. More potassium, cal- 
cium and magnesium were retained during the fruit-juice 
period. 

Diet in Scurvy. — The prophylaxis of scurvy consists of 
breast feeding when possible, and when this is impossible, in 
feeding raw milk and in the early addition of fruit juice 
(usually sweet orange juice) to the infant's diet. If the 
milk supply is such that it must be heated to make it safe, 
pasteurization is preferable to boiling, as pasteurization 
probably injures the antiscorbutic properties of milk less 
than boiling. Infants fed on the various proprietary infant 
foods, especially those that are made up without milk, are 
liable to develop scurvy. If one of these foods has to be 
used for any length of time orange juice should be added to 
the diet as soon as possible. Potato juice, made by mashing 
raw potato into a pulp with cold water and straining through 
cheesecloth, may be used to dilute the milk, and acts as does 
orange juice. 

When scurvy is present the infant's diet should be changed 
so as to furnish those articles of food which we know will 
effect a cure. All heating of the milk should be stopped and 
a good raw milk used in making up the food. If the milk is 
diluted with a cereal water, the latter should be cooled 
before mixing with the milk. • Some fruit juice should be 
begun at once. Sweet orange juice is the best and it may be 
diluted with water and sweetened if necessary. Better re- 
sults will be obtained if as much as two ounces is given each 
day. A good method is to give one ounce an hour before 
the forenoon feeding and the other before the late afternoon 
feeding. It should not be withheld because of loose undi- 
gested stools. Other fruit and vegetable juices have anti- 
scorbutic properties, but they have no advantages. Mashed 
potato (one tablespoonful each day) may be added to the 
diet of older infants, and the use of potato water instead of 

1 Tr. Assn. Am. Phys., 1912, xxvii. 514. 



BERIBERI 5-41 

cereal water as a diluent has been suggested by Hess and 
Fish l In general the antiscorbutics are most abundant in 
citrous fruits and cabbage leaves, less in tubers. There is 
enough vitamine in one pound of potato, less of cabbage, or 
one orange to protect from scurvy. 2 

The effect of heat on the antiscorbutic properties of vari- 
ous foods is different. Lemon, orange and raspberry juices 
are little if any affected by a temperature of ioo° C. for con- 
siderable periods of time. Vegetable juices are more easily 
affected by heat. The experimental evidence regarding the 
effect of heat on the antiscorbutic properties of milk is con- 
flicting, but clinical evidence seems to show that heat does 
damage these properties and furthermore that the damage 
varies directly with the degree and duration of the heating. 

After six months one may readily add the orange juice, 
lemonade, soup made with carrots, potato, beef juice, broths 
and potato water. 

In older children and adults who are so situated dieteti- 
cally that they are apt to develop scurvy, prevention by tak- 
ing any one of the antiscorbutic articles of diet is, of course, 
the only sensible procedure. When scurvy has actually 
developed, fresh vegetables, fruits, especially oranges, lemons, 
limes and apples (underdone) and raw meats will all effect a 
cure. Certain dried fruits and vegetables are also good 
antiscorbutics — e. g., dried apples, dried tomatoes, straw- 
berries, etc. Lime juice has an especially high reputation as 
an antiscorbutic and can easily be taken on trips where there 
is any danger of the development of scurvy. The main thing 
about a diet to prevent any danger from scurvy is that all 
the food shall be fresh, or if a part of it is necessarily dried, 
salted, or smoked, to always provide a certain amount of 
fresh food element. 

BERIBERI. 

The discovery of the cause of beriberi and its practical 
application to the diet of Eastern peoples has been one of the 
romances of medicine and deserves reading for its historical 
interest alone. 

Beriberi, which is a toxic polyneuritis, has been abundantly 
proven to be a "deficiency" disease, due to a lack of some 
element in the food which, although known to exist, has 
never been actually demonstrated — the name vitamine g;iven 
to this substance is not equally agreeable to all scientists, 
but is more or less in general use. In each deficiency disease 

1 Am. Jour. Dis. of Child., 1914, viii, 385. 

2 Brit. Med. Jour., 1918, i, 183. 



542 DEFICIENCY DISEASES 

the absence of the specific vitamine is responsible for the 
disease. 

While beriberi occurs for the most part among people who 
make their diet largely of polished rice, it is not found exclu- 
sively among rice eaters, but may also develop on a diet of 
white bread, sago, or in fact any food naturally poor in vita- 
mines, or made so by prolonged cooking, or cooking under 
pressure (Funk). It has also occurred among companies of 
men living on a mixed diet composed largely of tinned food, 
in which these vitamines were necessarily lacking. 

Cases have occurred following relapsing fever and has 
followed prolonged feeding on condensed milk. Osier says 
it sometimes follows any prolonged wasting disease, such as 
chronic dysentery and tuberculosis. 

A polyneuritis in birds 1 can be produced by a diet of pol- 
ished rice; or a synthetic vitamine-free diet, such as casein, 
lard, sugar and salts, will cause beriberi as rapidly as a pol- 
ished rice diet. 

Caspari and Moszkouski consider beriberi purely a toxic 
disease, but their results can be turned to account in proving 
the vitamine theory. This avian polyneuritis is readily 
cured or prevented by giving rice polishings or a watery ex- 
tract of rice polishings, for the preventive vitamine is found 
in the pericarp of the rice grain. If the rice is prepared in 
such a way as to leave this on, beriberi does not occur, pro- 
vided a liberal general diet is also allowed. Other substances 
besides the rice pericarp were found to be capable of prevent- 
ing beriberi and among these are ox cerebrum, cerebellum 
or liver, cow's milk, husked filberts and cheese — oddly 
enough human milk was less protective than cow's milk. 
Yeast vitamines have also proven most efficient in curing 
polyneuritis. "Beriberi occurs thus on a stagnant diet with 
a negative or insufficient supply of beriberi vitamines." 
(Funk.) i 

The dietary treatment is a simple matter from a prophy- 
lactic point of view and avoidance of a polished rice diet com- 
bined with a liberal supply of nitrogen and " fresh" foods is 
entirely capable of preventing its occurrence. This was well 
illustrated in the Japanese Navy, where formerly beriberi 
was very prevalent, and simply by giving unpolished rice 
and a larger proportion of nitrogenous foods, the disease has 
entirely disappeared from the service. 

When once the disease is established it is a matter of great 
difficulty to influence its course, as anatomical changes occur 
and are not to be easily overcome. Hence, though we may 

1 Eijkmaa: Virchows Archiv., 1897, cxlviii, 523. 



PELLAGRA 543 

give foods high in beriberi vitamines, the progress toward 
health is slow and sometimes no result at all is accomplished 
toward a cure by dietary regulation. On the other hand, 
mild cases are not infrequently relieved and undergo sponta- 
neous restitution. 

The diet should contain a fairly high percentage of protein, 
120 to 150 gm. (3 to \V 2 oz.), largely made up of fresh milk r 
eggs and meat that is lightly cooked; green vegetables, fruits, 
farinaceous food of all sorts and rice polishings mixed with 
the cereals, one or two tablespoonfuls at least twice a day. 
On such a diet as this, even without the rice polishings, beri- 
beri will not occur, and if once established such a diet com- 
bined with rest in bed and general hygiene will do all that is 
possible to favor a cure. 

Xeropthalmia. — Xeropthalmia is the most recent condi- 
tion definitely to be classed among the deficiency diseases 
and is a rare disease due apparently solely to the lack of 
fat soluble A in the diet. It is observed in adults princi- 
pally who have been on a monotonous diet with practically 
no animal fat such as egg, milk or butter fat, and consists 
of a yellowish discoloration about the eyes which later be- 
comes inflammatory and eventually destroys the sight 
unless checked by proper diet. The remedy is found simply 
in giving these forms of animal fat with a generally nourish- 
ing diet. Vegetable fats such as olive oil, cottonseed oil, 
etc., do not contain fat soluble A and therefore exert no 
curative influence. 

PELLAGRA. 

The etiology of pellagra has been a source of continued 
thought and experimentation for many years and first one 
and then another theory has been advanced in explanation. 
The spoiled maize theory, the bad hygiene and poor sewer- 
age disposal theory, the infectious theory, the theory that it is 
an acidosis the result of a carbohydrate or alcohol diet with 
practically no protein 1 and finally the theory that traces its 
origin to a dietetic fault whereby pellagra is brought about 
by lack of vitamines in the diet are a few of the more recent 
contributions. Jobling 2 studied the alkaline reserve of the 
blood in pellagra but found it did not vary from normal in 
either the acute or chronic cases, therefore it is not an acid- 
osis or alkalosis in this. In practically all forms of treat- 
ment that have given any degree of success, Goldberger 
finds that there was a simultaneous change in the diet of 

1 Yarbrough. Med. Rec, 1917, xcii, 892. 
- Jour. Am. Med. Assn., 1917, lxix, 2026. 



544 DEFICIENCY DISEASES 

the patients toward a better balanced ration. From work 
which he has done among pellagrins a change in the diet 
from a one-sided, principally carbohydrate diet, to a better 
balanced selection of foods, seems to show that this one factor 
is capable of preventing pellagra, On the other hand, by 
taking people off a mixed diet and placing them on a one- 
sided, largely carbohydrate diet, he was able to produce the 
disease in over 50 per cent, of the squad of prisoners who were 
the subjects of the experiment. His conclusions are cer- 
tainly more in line with the modern conception of the defi- 
ciency diseases, such as beriberi and scurvy, and deserve to 
be quoted and are as follows: 1 

Goldberger's Conclusions. — 1. "Diet is the common fac- 
tor in the various methods of treatment recently advocated. 
The marked success claimed for each of these methods must 
logically be attributed to the factor (diet) which they have 
in common. 

" 2. The value of diet in the prevention of pellagra has been 
tested at two orphanages and at an asylum for the insane, 
endemic foci of the disease, marked increases in the fresh 
animal and leguminous protein elements of the institution 
were made. Of the group of pellagrins on the modified diet 
at the insane asylum, 72 remained continuously under the 
observation up to October 1, 191 5, or at least until after the 
anniversary date of their attack of 19 14, not one of this group 
has presented recognizable evidence of a recurrence, although 
of a group of 32 controls 15 have had recurrences. Pellagra 
may therefore be prevented by an appropriate diet without 
any alteration in the environment, hygienic or sanitary, 
including the water supply. 

"3. The reverse was demonstrated on voluntary convicts, 
who were promised their freedom, by feeding a one-sided 
diet, chiefly carbohydrate (wheat, corn and rice), a diet 
from which fresh animal proteins and legumes were excluded. 
Six out of 1 1 developed pellagra, none of the controls did. 

"4. For practical purposes of preventive medicine it 
would seem to be of fundamental importance to recognize 
that the pellagra-producing dietary fault, whatever its inti- 
mate nature or however brought about, is capable of correc- 
tion or prevention by including in the diet suitable propor- 
tions of fresh animal and leguminous protein food." 

A house to house study of pellagrins and non-pellagrins 
showed the following factors: 

1. A physiological defective protein supply. 

2. A low inadequate supply of fat soluble and water 
soluble vitamines. 

1 Jour. Am. Med. Assn., February 12, 1916, p. 471. 



PELLAGRA 545 

3. A defective mineral supply in the diet. 1 

Goldberger concludes his observations by saying that "a 
definite conclusion as to the intimate mechanism involved in 
bringing about or preventing the disease by diet cannot be 
drawn from the available data. " On the other hand the 
report of a commission on pellagra comes to this conclusion : 

1. That it is the result of a distinct poison dependent 
indirectly at least on poor sanitation. 

2. That while devitalizing influences such as poor food, 
over- work, disease, etc., may render individuals susceptible, 
they do not produce the disease singly or combined. 2 

The Thompson-McFadden Commission places the blame 
entirely on poor sanitation. 

Although his conclusions have been strenuously combated 
it would seem as if so far they offer the best method at one's 
command for combating this strange disease, time and fur- 
ther experience being necessary to establish the apparent 
facts on a firm basis. 

Funk's 3 belief is that "beyond doubt pellagra has a close 
connection with maize." According to his theory it is due 
to a lack of vitamines in maize as it is milled, whereby the 
pericarp is removed — comparable to beriberi in its relation to 
polished rice. It is certainly a fact that pellagra occurs prin- 
cipally in sections of the country where maize forms from 74 
to 84 per cent, of the daily ration. Nevertheless many people 
who have eaten corn products so extensively do not contract 
the disease and pellagra develops at times in people who 
have never eaten corn. There was no marked dietary fault 
among 500 cases of pellagra which occurred in Illinois, an 
observation, which if correct, is the strongest proof presented 
against Goldberger's theory. 

Diet in Pellagra. — Since at present it is not possible to 
state the absolute undisputed cause of pellagra it would 
seem the wisest plan in choosing a diet for these people to 
place the patients in the best possible hygienic surroundings, 
avoid maize in every form and furnish a general mixed diet 
with 100 to 125 gm. (31^ to 434 oz.) of protein, largely made 
up of animal and leguminous protein with a total caloric 
value of 30 to 35 calories per kilo. Fiesh vegetables and 
fruits are also essential unless there is diarrhea, in which 
case no vegetables rich in cellulose should be used, but only 
puree vegetables, principally puree of beans and peas or len- 
tils. 

1 Goldberger. New York Med. Jour., 1918, cvii, 1146. 

2 Jour. New Med. Assn., 1918, x, No. 4, 165. 

3 Practitioner, 1913, i, 940; and Biochem. Bull., 1916, v. 

35 



546 DEFICIENCY DISEASES 

Milk is perhaps the most important single food in balanc- 
ing a diet in preventing or curing pellagra according to Gold- 
berger, and where a deficient supply of lean meat and green 
vegetables only is available one and one-half pints of milk 
(sweet or buttermilk) should be given two or three times a 
day. This in addition to the customary diet will practically 
in all instances protect from an attack of pellagra. 1 Tis- 
dale 2 eliminates all carbohydrate from the diet giving a 
large amount of protein food. If there is nausea or vomit- 
ing only milk, meat broths and fresh fruit juice are given, 
salt solution by enema and hypodermoclysis is also good. 
In severe diarrhea an examination of gastric chemistry 
should be made, and if deficient, dilute hydrochloric acid and 
pepsin are given. In some cases there may be a deficiency 
of pancreatic enzymes and it is often a good plan to give 
these in enteric coated pills or capsules. 

Goldberger recommends the following minimum diet as 
preventive of pellagra: 

Breakfast: Sweet milk, daily, oatmeal boiled, with butter 
or milk, q. 2. d. Boiled hominy or mush with meat 
gravy or milk every other day. Light bread or 
biscuit {yi soy bean meal) with butter, daily. 
Dinner: Meat, fish, fowl, maccaroni and cheese once a 
week. 
Dried beans or cow peas two or three times a week. 
Potatoes (Irish or sweet) four or five times a week. 
Rice two or three times a week with stew or beans. 
Green vegetables (cabbage, Gallards turnips, greens, 
spinach, snap beans, okra, all especially good), 
three or four times a week. 
Corn bread ( H, Soy meal) daily. Butter-milk. 
Supper: Light bread or biscuit ( V 4 Soy meal) daily. 
Butter-milk, daily. Stewed fruit (apples, peaches, 
prunes, apricots), three or four times a week on 
days when no green vegetable is given for dinner. 
Peanut butter twice a week. Syrup once or twice 
a week. 

1 Pub. Health Rep., 191 8, xxxiii, 487 (Washington). 

2 Jour. Florida Med. Assn., 1916, xiv, 137. 






CHAPTER XXIX. 
DIET IN DISEASES OF THE NERVOUS SYSTEM. 

The dietetics of organic nervous diseases are with a very 
few exceptions exceedingly unsatisfactory, while in some of 
the so-called functional cases more may be expected. 

The etiology of so many diseases of the nervous system is 
either obscure or so impossible of influence by diet (e. g., 
lues), that it leaves but a small field in which to diet these 
cases successfully in the light of their causation. Among 
the organic conditions that may be helped or influenced by 
diet are neuritis, epilepsy, insanity and apoplexy. Among 
the functional cases are neuralgia, periodic headaches, mi- 
graine, neurasthenia, chorea and digestive neuroses. 

ORGANIC NERVOUS DISEASES. 

Neuritis. — In order to treat any form of neuritis success- 
fully, it is absolutely necessary to make an etiological diag- 
nosis. Is it due to a toxicosis of some sort as lead, alcohol, 
gout, arsenic, following infectious disease, or is it due to an 
infection or pressure? When the exciting cause is found and 
removed the battle is already more than half won. Little 
need be said regarding the role alcohol plays in the produc- 
tion of neuritis and that its use should be interdicted at 
once. Patients with alcoholic neuritis are usually under- 
nourished and need special attention on this account or they 
are the subject of a chronic alcoholic gastritis and have to 
be dieted with this in view (see p. 347). 

As the course of alcoholic neuritis is often of months' 
duration and usually much sleep is lost on account of the 
pain, ample opportunity is given for these people to get in a 
bad state of subnutrition. 

In a gouty neuritis, diet also plays a distinct therapeutic 
role and should be treated as any case of gout, giving a pur- 
ine-free diet at first and later one with a low purine content 
(see Gout, p. 504). 

Where the neuritis is of obscure origin but the patient is 
either in a condition of over- or undernutrition too much 
importance cannot be placed on the necessity for regulation 
of the diet to meet either of these conditions, as without this, 
other therapeutic measures will doubtless fail. In these 
cases as well, constant attention to the intestinal functions 

.547 



548 DIET IN DISEASES OF THE NERVOUS SYSTEM 

is necessary and elimination promoted there by rectal 
salines or colon irrigations or both, as undou btedly a certain 
number of cases of obscure neuritis have their origin in a 
faulty bowel elimination. 

The dietetics of lead or arsenical neuritis have only to do 
with preventing the ingestion of these poisons and so not 
interest us otherwise except when as a result of a chronic 
toxicosis the general nutrition suffers. Neuritis due to lack 
of accessory substances in the food or vitamines, e. g., beri- 
beri has been dealt with separately in the Chapter on Defi- 
ciency Diseases. 

What has been said of neuritis applies equally to the neu- 
ralgic states, and these are especially seen in individuals who 
are overfed and underexercised. 

Epilepsy. — Epilepsy has been rather a dietetic storm cen- 
ter, much having been written pro and contra on the influence 
of diet as modifying either the frequency or severity of the 
attacks. Those who insist upon the influence of diet point 
to the fact that epilepsy is frequent among carnivorous ani- 
mals but rare in herbivora, Turner and Stewart 1 saying that 
"a vegetable diet, salt starvation and above all a purine-free 
diet permit the bromide salts being reduced to a minimum." 
On the whole Schloss 2 concluded that the nature of the diet 
had little or nothing to do with the frequency or severity of 
the attacks, but he did find in fact that reducing the sodium 
chloride intake in addition to giving bromides exerted a 
marked and favorable effect on the attacks. This point 
seems fairly well established and should always be considered 
in prescribing a suitable diet for epilepsy. Despite Schloss's 
contention that diet has no material effect on the epileptic 
seizures the large majority of clinicians distinctly favor a low 
protein diet and one particularly low in purine bodies, as 
Turner 3 has emphasized. The deleterious effect of the high 
protein is no doubt due to the frequency with which the 
ingestion of considerable amounts of meat products is accom- 
panied by intestinal putrefaction and absorption of intesti- 
nal by-products. An indication of this is indol in the urine, 
and while this has in itself often no ill-effect, it is frequently 
the index of other intestinal poisons which may still further 
lower the threshold of nervous stability, so leading to the 
easier production of an epileptic seizure. 

The prevention, therefore of intestinal decomposition is 
absolutely indicated 4 and every means should be taken to 

1 Text-book of Nervous Diseases, p. 582. 

2 Wien. klin. Wchnschr., 1901, xiv, No. 46. 

3 Practitioner, 1906, lxxvi, 476. 

4 Dana: Text-book of Nervous Diseases, p. 534. 



ORGANIC NERVOUS DISEASES 549 

obviate its production and to assist in its limitation and 
elimination when present. Among the best means to pre- 
vent or relieve this condition is the maintenance of a low pro- 
tein diet with the emphasis put on the reduction of animal 
protein, particularly meat, placing the patients for a few 
days on a strict vegetarian diet and later on a lacto-ovo- 
vegetarian regimen as already explained under vegetarian- 
ism. When the indican, as the index of intestinal poison, 
is reduced to a minimum, one may again add small amounts 
of meat, particularly if the patients are able to take a good 
deal of out-of-door exercise or work, but making meat the 
least constituent of the protein ration. In addition to proper 
diet in intestinal decomposition consideration must be given 
to promoting intestinal peristalsis and the mechanical re- 
moval of by-products by colon lavage. 

When these dietary regulations are carried out it will be 
found possible to control the seizures with the minimum 
amount of bromide salts, particularly if the sodium chloride 
intake be kept at a low level, even at times to the point of a 
so-called salt-free diet, particularly in adults. 

Aside from these restrictions an epileptic may eat almost 
anything that is in itself digestible, remembering always that 
acute or chronic indigestion favors the production of the 
attacks and included under this must also be mentioned 
chronic constipation. 

A new method of treating epilepsy has been devised by 
Concklin, of Battle Creek, Michigan. In this the patients 
are put to bed and starved for from ten to fourteen days, 
allowing of course all the water desired. After this initial 
period of starvation they are again gradually fed, beginning 
with light foods — egg albumin in orange juice, cereals, and 
so gradually back to a fairly generous diet. In severe cases 
a second fast is sometimes given for a shorter period. Many 
cases cease to have attacks after the first forty-eight hours 
of the fast. The treatment is still in its experimental stage. 

Insanity. — Practically the only dietetic problems of import- 
ance that arise in connection with the various forms of in- 
sanity are the questions of forcible feeding and the preven- 
tion of indigestion or actual blocking of the esophagus by 
bolting large masses of food. The latter is easily guarded 
against by serving only food that is well-cooked and finely 
comminuted. As to the question of forced feeding by gav- 
age, there is no question at times as to its necessity since it 
must be done in cases of mania or extreme melancholia 
where the patients refuse food. It must not be forgotten 



550 DIET IN DISEASES OF THE NERVOUS SYSTEM 

however, that even these patients may refuse food on account 
of lack of appetite or from some actual disability, such as 
painful deglutition, but when it is decided that forced feed- 
ing (or suralimentation as it is called) is needed, the method 
to be followed is as follows: If the patient is apathetic and 
will allow the passage of the stomach-tube with little or no 
restraint it may be passed and fluid food according to the 
appended formulae may be used three or four times a day. 
If, on the other hand, there is active resistance to the process 
the patients must be forcibly restrained either by strapping 
to a high-back chair or probably better by restraining them 
flat on the bed and inserting the mouth gag gently. A very- 
good form of gag is a wooden cork with a hole in it large 
enough to allow the passage of the stomach-tube through it 
and insert this cork between the teeth; it should be made 
with a flange on either end to prevent it from slipping out 
from between the teeth and of course a string attached to 
the outer flange to prevent it from slipping down the throat. 

The best foods to use for this forced feeding are milk, 
cream, beef powders, beef meal, puree of beans and peas, 
cereals, eggs, cane-sugar and lactose. A convenient basis, 
for at least some of the feedings, may be found in the milk, 
cream and lactose formulae under Diet in Typhoid Fever 
(p. 575) , to which can be added the other foods suggested. 

In order to maintain nutrition and body weight it is of 
course necessary to calculate the food requirements for the 
patient's normal weight and height and feed accordingly. 
Debove uses 1000 c.c. (1 qt.) of milk, 100 gm. (3^ oz.) of 
meat powder and one egg, three or four times daily. 1 For a 
sample formula this is very well but whether or not it is suffi- 
cient for a given individual will depend on the actual food 
requirements, calculated on the ordinary basis, 30 to 40 calo- 
ries per kilo of body weight, which must always be reckoned 
out, remembering that the restless insane burn up more food 
than the melancholic. 

Apoplexy. — The dietetics of apoplexy might well be 
divided into prophylactic diet and that actually to be em- 
ployed in the presence of a cerebral hemorrhage. In the 
preventive diet it is necessary to warn patients with high 
blood-pressure or marked arteriosclerosis or both that they 
should eat sparingly of all foods but especially of the purines 
of animal food-stuffs, as tending to raise blood-pressure; 
they should never take a very hearty meal, particularly at 
night and should abstain from alcoholic drinks at all times. 
A diet largely vegetarian or ovo-lacto-vegetarian is best 

Thompson: Dietetics, p. 514. 



FUNCTIONAL NERVOUS DISEASES 551 

suited to these people, taking the best meal at midday and a 
light supper. 

Continuous and persistent overeating is probably a fre- 
quent acquired cause of hypertension and arteriosclerosis 
and should be discouraged at any time of life, but particu- 
larly so late in life where an overindulgence is apt to prove 
disastrous. 

When once an apoplexy has occurred the dietetic indica- 
tions are to reduce the volume of blood as much as may be 
and lower blood-pressure. If the patient is plethoric or 
obese the best way to bring this about is to give no food or 
even water for several hours after the hemorrhage, but to 
promote free intestinal evacuation in every way by quick 
cathartics such as elaterin, croton oil, castor oil or repeated 
doses of concentrated solution of magnesium sulphate, I or 2 
drams every half-hour, in 2 ounces of water, until thoroughly 
effectual. After six to eight hours one may begin with small 
quantities ot milk. Probably one of the best methods is to 
place these patients on a Karell diet (see p. 310), beginning 
with 200 c.c. (6}i oz.) milk four times a day for four or five 
days then gradually increasing to soft foods as indicated in 
that dietary regimen. This has two advantages in that it 
gives little bulk and aids in reducing weight with consequent 
lowering of blood-pressure. This is about all one can do 
dietetically for these cases, but it is often surprising how 
effectual the method is in reducing the full bounding pulse 
so often seen, to one of lower tension and less volume. After 
the patients are again restored to their new normal, i. e., 
when either the results of the hemorrhage have disappeared 
or their permanence demonstrated, then what has already 
been said in regard to prophylaxis for these cases is indicated. 

FUNCTIONAL NERVOUS DISEASES. 

Migraine or Periodic Headaches. — Among the most trying 
conditions a physician is ever called upon to treat, migraine 
and periodic headache have few peers. At one time or 
another almost every variety of food has been blamed for 
these headaches and one can find diets based on the elimina- 
tion of one or another kind, some authorities vaunting a 
meat-free diet, others a diet low in hydrocarbons, still an- 
other curtailing the carbohydrates. As the etiology is prob- 
ably various so one dietetic treatment or another fits and 
relieves the symptoms or not as the case may be, so account- 
ing for similar results by dissimilar diets, e. g. } cases with 
gouty migraine may be helped by a purine-free diet; another 



552 DIE T IN DISEA SES OF THE NER VO US S YSTEM 

case with marked digestive acidity and fermentation will be 
helped most by a diet without sweets and low in starches; 
so that so far as is possible a correct determination of the 
etiological factors should be made if dietetic treatment is to 
be at all helpful in its results. Many cases with a markedly 
neurotic habit respond to no particular diet but must be 
treated generally if any favorable results are to be obtained, 
e. g., rest, hydrotherapy, exercise, suggestion, etc., diet play- 
ing only the usual nutritive role in maintaining a good phy- 
sical condition. 

In short, no specific directions can be given to cover all 
these cases, as they all respond differently, each must be studied 
separately and often when one fails to identify the under- 
lying cause, recourse must be had to experimentation, try- 
ing first one, then another diet until one becomes convinced 
that certain omissions are helpful. In this the patient's 
feelings are often valuable, for many of them soon learn to 
know whether one or another class of foods cause them to 
feel worse or better. The presence of decayed teeth is often 
associated with periodic headache and must be borne in 
mind as an etiological factor. Heredity, too, is frequently 
seen to be a factor, as a parent with these headaches is very 
apt to beget a child who later develops the same trouble. 
Again, some children who have epilepsy as children, out- 
grow this and develop periodic headaches which apparently 
represent another expression of the nervous explosion which 
in their early youth resulted in a convulsion. 

In some cases we find a vegetarian diet with milk gives 
excellent results, particularly if the cause can be traced to a 
lithemic condition or a purine-free diet as already outlined, 
and most of them, unless they have their headaches in spite 
of hard labor, do best on a low (Chittenden) protein diet. 
As a matter of interest this condition is seldom seen in the 
laboring man, but more often in a highly organized and edu- 
cated man or woman, who lives more or less without regular 
exercise and with a tendency to overeating. 

In some way the impression cannot help but be a strong 
one that people who work hard, exercise freely, sweat more 
or less profusely at work are not often subjects of periodic 
headaches, facts which point the way to a rational work and 
dietetic cure. 

Hare 1 has thought that the best results have been obtained 
in his experience by reducing the " carbonaceous" material in 
the diet. This is accomplished by ordering a diet "mainly 
protein, 8 to 12 ounces cooked meat or fish with i}4 ounces 

1 Medical Magazine, 1907, xvi, 722. 



FUNCTIONAL NERVOUS DISEASES 553 

bread or toast and a little butter. Green non-starchy vege- 
tables are allowed. Tea and coffee with a little milk but 
no sugar. " On this the patients slowly lose weight, which is 
regularly taken and recorded. The carbohydrates and fats 
are cautiously increased in the form of bread, butter and 
milk until the weight remains stationary, "carbon equilib- 
rium being maintained on a minimum intake." 

In order to do this satisfactorily it is necessary to weigh 
the food and it is best to begin two weeks before an attack is 
expected. 

Chorea. — The etiology of chorea is somewhat obscure but 
occurring as it does, for the most part, after rheumatic infec- 
tion makes it pretty surely a result of this infection or intoxi- 
cation. Just how the nervous system comes to be involved 
is far from clear, but the fact remains that the individuals 
who are thus affected are usually found to be anemic, poorly 
nourished, and in need of physical up-building. The diet, 
therefore, which will accomplish most for these patients is a 
very nourishing one with emphasis placed upon the feeding 
of fattening foods in order that their nervous system may take 
part in the general up-building of the organism. So far as 
possible then these patients should be placed upon a fatten- 
ing cure with the addition of considerable quantities of cream, 
butter and cereals, and other carbohydrate foods without 
too great an allowance of protein, particularly the meat pro- 
teins; eggs cooked in any form, in custards, ice-cream, etc., 
should be freely used and with the fattening process there 
should go careful attention to the elimination, rest, light 
exercise later on, and freedom from all external and internal 
nerve irritants. In conformity with the latter suggestion 
the exclusion of tea or coffee from the diet is imperative. 
Where the digestion is good, it is often advisable to allow a 
glass of milk with cream or an egg-nog between meals and at 
bedtime, if this interferes with the consumption of three good 
meals a day the between-meal feeding should be omitted. 

Neurasthenia. — The causes of this protean disease are so 
numerous and far-reaching that for a complete discussion of 
the subject one must refer to the standard text-books on 
neurology. Predisposing causes are largely hereditary and 
as such outside the consideration of dietetics. There are 
certain physical conditions which predispose to its develop- 
ment and which are to some extent preventable by proper 
attention to diet. Thus, any condition of lowered vitality 
as that following influenza, typhoid fever and other pro- 
longed illnesses or severe operations, all act as causes, and 
can be, to a certain extent, guarded against, if the lowered 



554 DIE T IN DISEA SES OF THE NER VO US S YSTEM 

vitality can be combated from the start or altogether pre- 
vented by proper attention to diet and by guarding against 
the semi-starvation diets so often resorted to in the condi- 
tions named. When one considers the usual immediate 
causes such as worry, overwork, shocks, accidents, fright, 
all the forms of chronic unhappiness, and "ingrowing" 
thoughts, it is plain that diet is not specially concerned, ex- 
cept insofar as a properly fed body is less liable to worry, 
than one that is poorly nourished. The newer conception 
of the causation of many of the cases of neurasthenia include 
attention to various possible chronic intoxications, some of 
which are doubtless of digestive origin, such as chronic in- 
testinal stasis, chronic constipation, various chronic forms of 
gastro-intestinal digestive defect, besides the intoxications 
that arise from localized points of chronic infection often 
hidden or unsuspected, e. g., chronic tonsillar infection, 
tooth infections, low grade pelvic infections. In fact local- 
ized infection anywhere with resulting chronic absorption 
of the products of bacterial change with the well-known 
effects upon the blood causing an anemia, and the more 
remote effects upon the nervous system. All these possible 
factors must also be taken into account and weighed when 
trying to find the cause in a particular case of neurasthenia. 

Given a case, therefore, of neurasthenia what can we, as 
dieticians, do for the patient? 

In this decision we must have a clear idea of just how se- 
vere a case we have to deal with, for the lighter cases are less 
drastically treated than those which are severe or advanced, 
so that we may divide them into mild, medium severe, and 
severe in order to reduce the question to orderly discussion. 

The three great essentials of the treatment in these cases 
are: rest, diversion, diet, and regulated exercise. 

In the mild cases it is often only necessary to keep the 
patients in bed for half the day, let them rest and read and 
above all in a room to which air is freely admitted by open 
windows, or even better, out of-doors on a protected porch. 
The remainder of the day they may go about their affairs 
with caution, resting before dinner and getting to bed early. 
The diet in these cases (particularly if undernourished) should 
be pushed, giving food frequently and in concentrated form. 
This may be done by following Keating 's 1 diet as follows: 
6 a.m. 240 c.c. (8 oz.) strong beef tea, hot. 
8 A.M. Half a glass of iron water. Breakfast of fruit, 
steak and coffee, 240 c.c. (8 oz.). Milk with 
extract of malt and citrate of iron, quinine 6 
grains. 

1 Thompson's Dietetics. 



FUNCTIONAL NERVOUS DISEASES 555 

io a.m. Electricity. 

12 noon Milk, 240 c.c. (8 oz.) with malt. 
2 p.m. Dinner with half a glass of iron water, followed by 

a glass of milk with the malt. 
6 p.m. Third dose of iron water with light supper of 
fruits, bread and butter and cream. Glass of 
milk and malt. 

10 i.m. Beef soup, 120 c.c. (4 oz.) preceded by massage 
with cocoa oil for one hour. 

In the more severe cases it is necessary, in order to get 
good results, that the patients should be kept in bed and put 
upon some modification of the Weir Mitchell treatment, its 
rigor depending upon the severity of the case and the length 
of time that the routine should be kept up. 

Weir Mitchell Diet and Treatment. 1 — The Weir Mitchell 
treatment for various conditions of malnutrition and neur- 
osis consists essentially in absolute seclusion of the patient, 
preferably away from home with a nurse who is entirely 
unknown to the patient, but chosen by the physician for her 
qualities with special reference to the individual case. The 
nurse should be changed if she is a misfit with the patient. 
The patient is kept in bed during the treatment which is 
from four to eight or more weeks. Massage and electricity 
(faradic) is given daily in hour or hour and a half periods and 
feedings which are based on the following routine. 

Milk is the food of first importance with Mitchell, for he 
found that on an exclusive milk diet for a few days patients 
promptly lost their various digestive symptoms. When neu- 
rasthenia is combined with obesity the Karell cure for a fort- 
night or less is the best method of procedure particularly in 
the cases of extreme fatness with anemia. Skimmed milk 
is especially recommended as most favorable to the dyspep- 
tics given two-hourly with or without lime water. The milk 
should be slowly sipped and when it is disgreeable or nausea- 
ting can be flavored with tea, coffee, caramel or salt. If the 
milk causes "acidity" the use of alkalies is indicated. At 
first 4 ounces are given every two hours, and as the amount 
is enlarged the periods may be lengthened to three hours 
with a total of 2 quarts of milk daily. 

For the first few days the patients lose weight but then 
remain stationary or even gain. Patients on this diet are 
usually sleepy after a few days. Constipation and coated 
tongue are usual and have to be attended to, and Mitchell 
says on a skimmed-milk diet uric acid disappears almost 
entirely from the urine but reappears as soon as a mixed 

1 "Fat and Blood." 



556 DIET IN DISEASES OF THE NERVOUS SYSTEM 

diet is begun. The addition of various farinaceous and milk 
preparations to the milk diet such as malted milk and Nestle's 
food, etc., is often useful. Ordinarily after four to seven 
days a light breakfast is allowed, in another couple of days 
a chop is given as a mid-day dinner and again in a day or two 
bread and butter are allowed three times a day. After ten 
days it is usually possible to allow three full meals, together 
with 3 or 4 pints of milk given at or after meals instead of 
water. After ten days Mitchell also orders 2 to 4 ounces of 
a good fluidextract of malt before each meal. The foods 
actually used are largely according to the patient's wishes 
but butter in considerable amounts is urged and a cup of 
coffee or cocoa is allowed the first thing in the morning. 

At the end of the first week a raw meat soup is added, made 
as follows: One pound of rare beef chopped up and put in 
a bottle with 1 pint of water and 5 drops of strong hydro- 
chloric aid. This is allowed to stand all night on ice and in 
the morning the bottle is placed in water at no° F. and kept 
for two hours at this temperature. It is then strained 
through a cloth under pressure and the resulting fluid given 
in divided doses three times during the day. A little more 
pleasant taste is obtained by first roasting the meat slightly 
on one side. When the patients are on full feedings, iron is 
given, also cod-liver oil, either by mouth or rectum, when 
there has been much loss of flesh. 

Under this regimen the increase of weight and well-being 
is often extraordinary but there is much dependent upon 
the physician's attention to details and his ability to carry 
the patient along psychologically; in other words, the same 
treatment and regimen will succeed in the hands of one man, 
and not with another. One criticism that has been offered 
is that while the patients do gain they lose the additional fat 
very shortly after they are allowed up. 

This is not a fact if the massage has been kept up vigor- 
ously and steadily, for this in conjunction with the elec- 
tricity, prevents the patient's from getting " soft, " the added 
weight being firm and sound. 

A convenient routine founded upon the Weir Mitchell 
diet by J. K. Mitchell is as follows: 

7.00 a.m. Cocoa. Cold sponge with rough rub. 

8.00 A.M. Breakfast with milk. Rest an hour afterward.. 

10.00 a.m. Milk, 240 c.c. (8 oz.), peptonized. Massage. 

12.00 m. Milk as soup. Reading aloud by nurse. 
1.30 p.m. Dinner. Rest one hour afterward. 
3.30 p.m. Peptonized milk, 240 c.c. (8 oz.). 
4.00 p.m. Electricity. 



FUNCTIONAL NERVOUS DISEASES 557 

6.00 p.m. Supper with milk. 

8.00 p.m. Reading aloud by nurse, half an hour. 

9.00 p.m. Light rub by nurse with drip sheet. 

10.00 p.m. Peptonized milk, 240 c.c. (8 oz.) with biscuits. 

During the night a glass of milk is needed. 

With dinner and supper give malt extract 240 c.c. (8 oz.) 

After each meal some tonic mixture with iron if anemia is 
present. 

Digestive Neuroses. — -These are of many sorts and kinds, 
some referred to the stomach and accompanied either by an 
excess or diminution of acid values in the gastric secretion or 
they may be referred to the intestinal tract with constipa- 
tion or diarrhea or even the passage of mucus as the cardinal 
symptoms, with or without abdominal pain. 

Then there is the well-known type of vomiting occurring 
in nervous individuals often most trying to deal with. Where 
these digestive neuroses are severe a Weir Mitchell regimen 
has a very salutary effect even though it is not necessary 
perhaps to carry it out to the last letter of detail, but the 
effect of absolute rest combined with the skimmed-milk diet 
in increasing amounts is most useful. In fact there are many 
cases of gastro-intestinal disturbance in which no definite 
lesion or cause can be determined but in which a graduated 
milk diet combined with rest seems to produce the desired 
result, doing away with the symptoms. 1 

Insomnia. — Insomnia has so many causes that it is quite 
impossible to give off-hand, dietary advice to meet all the 
general factors. One must make a correct etiological diag- 
nosis before it will be possible to prescribe a diet rationally; 
for depending upon whether the cause is digestive, nervous or 
from organic disease such as chronic nephritis, arteriosclero- 
sis, or old age the diet will all have to be reckoned on the 
basis of the underlying trouble. If we can exclude definite 
organic disease and digestive errors we have left an idiopathic 
form of insomnia which is for the most part a functional 
neurosis. Patients get the habit of not sleeping until a cer- 
tain hour or not until after a certain hour or of waking up at 
a particular hour, with great regularity. 

There are many methods of general hygiene which must be 
brought into play in order to bring about the best result, 
e. g., prevention of exhaustion, bathing, suitable exercise, 
clothing, air and food, all of which are factors in producing 
insomnia or of perpetuating it. People drop into the habit 
of taking drugs with great ease and one constantly finds 

1 For further discussion of digestive neurosis see Chapter on Gastro-intestinal 
Diseases. 



558 DIET IN DISEASES OF THE NERVOUS SYSTEM 

patients taking trional, sulphonal, medinal, veronal, etc., 
more or less frequently, often with disastrous results so far 
as the general health is concerned; but with measures for 
insomnia other than diet we have nothing directly to do and 
one must be referred to neurological text-books for all such 
assistance. Diet does play a very distinct role in the 
treatment of the idiopathic form of insomnia, and it is of 
course of chief importance in those cases due to a disturbed 
digestion. 

The entire day's dietary for the insomniac should be of the 
simplest sort, avoidance of all indigestible substances at 
every meal, making the heartiest meal in the middle of the 
day. The supper should be light, free of stimulants, tea, 
coffee, alcohol and tobacco or much meat, as meat products 
are all distinctly stimulating to most persons. At bedtime 
it is often a good plan to take a glass of milk, hot or cold, as 
preferred, sipped slowly. Malted milk or any other flavor 
may be added to the milk to taste. If milk in any form is 
distasteful a small cream-cheese sandwich, piece of bread 
and butter or fruit, in fact any simple article of food may 
often be taken on retiring with advantage. In certain cases 
a split of ale in small amount, not over one glass, may produce 
the same effect. 

If the patient falls asleep easily but awakens in the night, 
particularly toward morning, sleep may often be obtained if 
a glass of milk or sandwich or hot cocoa (in a thermos bottle), 
if taken immediately on waking, not waiting to see if sleep 
will come itself. If one waits, then the chances are that 
even though the food is taken later, it does not have the same 
effect and wakefulness continues. 

Delirium Tremens. — While it may seem at first that the 
question of diet does not enter very vividly into the question 
of delirium tremens, or hyperalcoholization, as a matter of 
fact it is of the utmost importance, and if properly carried 
out may readily turn the scale in favor of recovery rather 
than death. Almost invariably it will be found out on in- 
quiry — or failing this, may be safely assumed — that during 
the period of excessive alcoholic use the patient has taken 
little or no food. Excessive drinking and food taking do 
not go together, so that these patients while they have been 
supplied with a considerable number of heat units in taking 
the alcohol (7.2 calories per c.c.) which has somewhat spared 
the fat combustion, are virtually in a state of nitrogen star- 
vation, besides being poisoned by the products of their own 
perverted metabolism. What they need, after a thorough 
purgation, is a large amount of nourishment with a high pro- 



FUNCTIONAL NERVOUS DISEASES 559 

tein content easily taken and digested. Milk fills these indi- 
cations particularly well and should be given every hour, 
preferably hot, and 8 to 10 ounces at a time, depending on 
the size of the patient. After the first twenty-four hours 
the amount may be increased or the milk may be modified 
upward, so to speak, by the addition of cream and lactose, 
as used in typhoid fever (see p. 575). After forty-eight hours 
the interval may be lengthened to two hourly feedings and 
usually, if the case is progressing well, soft solids may then 
be allowed. This plan of feeding combined with the pre- 
liminary catharsis (although we should not wait for the 
cathartics to act before giving the milk) and proper use of 
sedatives has in the writer's experience proved its worth 
many times. 

Nervous Anorexia. — Nervous anorexia is a well-known 
neurosis occurring in people who have undergone some 
severe mental shock or strain or it may develop as a sequel of 
any prolonged illness during which the nervous reserve has 
been unduly depleted. Whatever the cause, the condition 
is one of absolute anorexia; nothing whatever makes an 
appeal to the palate and the patient often refuses every kind 
of food unless actually forced to take it. Under these cir- 
cumstances the treatment is divided into general hygiene 
and diet. Under hygiene comes the general care of the pa- 
tient; hydrotherapy, suggestion — massage, exercises, etc. — 
all of which play a most important part in overcoming the 
underlying causes of the anorexia in a nervous system that 
is away below par. So far as the dietary management goes, 
one can try all sorts of ways to tempt the appetite with special 
foods, attractive preparation and insistence on the part 
of the nurse. At times the Weir Mitchell routine is of the 
greatest value, for this attacks the trouble at its source and 
the simplicity of the dietary regimen lends itself to success 
with these patients. In those patients who absolutely re- 
fuse nourishment one of two methods may be adopted ; feed- 
ing concentrated foods by gastric gavage three or four times 
a day as recommended in suralimentation, or by duodenal 
feeding as recommended by Einhorn. By either method a. 
large amount of food can be furnished independent of appe- 
tite which will gradually favorably affect the entire organism, 
building it up in spite of a complete disinclination to food, 
with the certainty that if sufficient progress can be made 
the appetite will presently return of itself and the difficulty 
in feeding will be at an end. 






CHAPTER XXX. 

ACUTE AND CHRONIC INFECTIONS. 

In the dietetics of the infections great advance has been 
made, taking the subject out of the realm of hypotheses and 
placing it on the solid rock of accurate experimentation, 
checked by calorimetry and the tracing of the protein meta- 
bolism. Great credit is due to Coleman, Shaffer and Du 
Bois for their painstaking work in typhoid, the results of 
which have formed the basis of much of our present ability 
to keep fever patients in a state of good nutrition, while 
formerly patients with acute infections were kept in a state 
of semistarvation, with resulting subnutrition amounting in 
many instances to emaciation. These same patients today, 
instead of losing 30, 40 or 50 pounds during a six weeks' 
typhoid, emerge from their illness with minor losses or none 
and in some instances showing actual gain in weight. The 
resulting shortening of convalescence and comparative free- 
dom from many of the complications of these infections 
have been some of the results obtained, and it is not to be 
doubted that the modern method of feeding in infections 
has had its decided influence on the prolongation of life. 

FEVER. 1 

The body temperature is regulated through two processes, 
chemical production of heat by an increased or decreased 
rate of oxidation ; and physical loss of heat through conduc- 
tion, radiation, evaporation, or excretion. There is a criti- 
cal air temperature, approximately 15 C. (59 F.) at which 
there is a balance between production and loss which does 
not affect the body temperature. The metabolism of fast- 
ing at the critical temperature represents the heat needed for 
the performance of the various functions of the body. Be- 
low this temperature the heat production, controlled by chem- 
ical regulation, rises or falls with variations in the external 
temperature, while above it heat production is slightly in- 
creased, and the regulation depends upon physical means. 
Between 20 and 30 C.(68° and 86° F.) the heat production 

Shaffer and Coleman: Arch. Inter. Med., 1909, iv, 538. Coleman: Tr. 
XVth International Cong. Hyg. and Demog., 1912, ii, 602. Carpenter: Am. 
Jour. Physiol., 1909, xxiv, 203. Coleman and Du Bois: and numerous other 
papers by other investigators. 

560 



FEVER 561 

is practically stationary; regulation is then dependent upon 
physical regulation, particularly upon increased evapora- 
tion. 

Factors which will tend to increase heat production and 
temperature are work, ingestion of food, particularly protein, 
exposure to various stimuli, such as cold, or the production of 
toxic substance in the body, as in fevers. Heat loss is in- 
creased by dilatation of the surface bloodvessels and excre- 
tion of water with subsequent evaporation; these processes 
are under the control of the nervous system. The rapid 
movement of the air surrounding the body assists in the re- 
moval of heat directly and indirectly through increased 
evaporation, provided the humidity be low. Conversely 
the stagnation of air and prevention of loss by radiation and 
clothing tends to conserve the heat within the body. 

The cause of increased heat production in fever is not 
known; it is closely associated with infection with bacteria 
and other organisms or the products of their activity, toxins. 
It may be that the organisms themselves stimulate directly 
the production of heat. The substances produced as a re- 
sult of their metabolic activities, particularly on protein, 
have been held to be the more specific stimulants to meta- 
bolism. 

The rise of the body temperature above the normal may 
be taken as an index of the intensity of intoxication, but in 
children a mild infection may be accompanied by a very high 
temperature, while in the aged a severe infection may cause 
only a comparatively slight rise, one or two degrees. 

An increase in temperature itself, provided it does not 
exceed a certain limit, 40 to 42 C. (104 to 107 F.) or, as 
has been suggested below, the temperature at which certain 
proteins begin to coagulate is not of itself harmful. This 
fact has been demonstrated with animals which were kept 
at a temperature of 40 C.(i04° F.), for weeks without showing 
signs of disintegration ; they were even more resistant to sta- 
phylococci, pneumococci, or B. coli inoculation than control 
animals, for they lived longer or even survived the infection. 

In fever an increase or decrease in the total metabolism is 
accompanied by a rise or fall in the body temperature; a 
subnormal temperature is associated with a rate of meta- 
bolism which is below normal. Metabolism in fever has been 
studied particularly in connection with typhoid fever. 

The idea has been prevalent that it was impossible or 
unwise to feed fever patients sufficient food to prevent loss 
of protein and that food was poorly utilized in fever. It has 

36 



562 ACUTE AND CHRONIC INFECTIONS 

been found, however, that when furnished with sufficient 
energy-yielding food and moderate amounts of protein, fever 
patients may be able to maintain their body weight and in 
some cases nitrogen equilibrium. Sufficient food must be 
given to enable the patient to meet the increased heat pro- 
duction, 40 to 50 per cent, above the normal, without using 
his own reserves for that purpose. 

While a normal man can maintain himself on a diet con- 
taining sufficient protein and yielding energy equivalent to 
but little more than his basal heat production, a fever patient 
requires a diet containing a quantity of energy-yielding foods 
far in excess of the expected metabolism, on the basis of his 
height and weight. Thus, a man producing 40 calories per 
kilogram per day cannot be brought into equilibrium unless 
he receive from 57 to 8j calories per kilogram; or a man of 
65 kilograms body weight, producing 2400 calories per day, 
would require from 3600 to 5000 calories to keep him in 
equilibrium. 

In convalescence the energy requirement more nearly 
approaches the calculated normal. A man who required Jj 
calories per kilogram to cover his energy requirement during 
a relapse, needed only 37 calories per kilogram a few days 
later during convalescence. The table on p. 63 gives the per- 
centage rise in the basal metabolism above the average nor- 
mal. 

Since the protein metabolism is increased during fever 
even with a diet high in calories a larger proportion of pro- 
tein is required than for the normal individual. That this 
is not due to the effect of a temperature rise to 40 C. or in- 
creased heat production has been demonstrated on men for 
short periods of time. Evidence points to some specific 
action, perhaps a toxic destruction of protein. 

Studies of the utilization of food by typhoid fever patients 
indicate that it is almost as complete as in health. Protein 
is as fully utilized as in normal individuals. Carbohydrate, 
when fed in amounts under 300 grams per day, appears in 
the stools only in traces; above this value 2 or 3 grams of 
reducing substances may appear. Fat is absorbed in large 
amounts but the percentage of absorption is slightly lower 
than the normal, particularly in the early stages of the 
disease. 

Objection has been raised to the ingestion of large quan- 
tities of food in fever on the ground that food itself is stimu- 
lating and therefore causes an increase in heat production 
when there is already an excessive liberation of heat. The 
work of the Russell Sage Institute of Pathology has de- 






FEVER 563 

monstrated that the rise in heat production usually ob- 
served upon the ingestion of food, particularly of protein, 
occurs only to a limited extent, 2 to 5 per cent., in typhoid 
fever, due, perhaps, to the increased rate at which the body 
is already metabolizing. This does not hold for all fevers, 
however, such as that in exophthalmic goiter. Because 
protein metabolism in fever cannot be reduced to the level 
of that of a normal person, protein ingestion in fever often 
merely serves to replace protein already disintegrating in 
increased quantity and such protein would not serve to in- 
crease the heat production (Lusk). From this work it is 
evident that there is no objection on a scientific basis to feed- 
ing most fever patients, on the contrary, experience seems to 
point to the desirability of adequate feeding. 

Diet in Fever. — In view of the experimental data, especially 
that presented by Coleman and Shaffer and Du Bois in their 
studies of metabolism in typhoid fever, we see that in order 
to maintain a patient's nitrogenous equilibrium it is neces- 
sary to give fairly large amounts of protein in the food; an 
allowance of 80 to 120 gm. is usually sufficient, provided 
large amounts of carbohydrate and fat are included in the 
dietary, for both these foods spare the protein combustion. 
The importance of this fact is realized when consideration 
is given to the condition of cloudy swelling of the kidneys, 
associated with any high temperature which renders them 
less capable of eliminating large amounts of nitrogenous 
products. Of the end-products of carbohydrate and fat 
combustion, C0 2 and water, C0 2 is given off by the lungs, 
and only water has to pass the kidney, a much simpler pro- 
cess than the excretion of nitrogen. 

As will be brought out later, the necessity for liberal feed- 
ing in fever depends largely on the disease present. If the 
infection is slight, mild or apt to be short-lived as in influenza, 
measles, etc., it is not necessary to plan the feeding cam- 
paign with such care as when we have a long-continued in- 
fection to deal with, as in typhoid,, typhus, tuberculosis or 
other long-standing pus infections, such as empyema. In 
the latter cases the necessity for preventing undue tissue loss 
is of the greatest importance, for any infection is better fought 
by a body that is well nourished than by one that is half 
starved. Besides the protein-sparing qualities of carbohy- 
drates they have another important function in fever, 
namely, that of favoring the production of the less harmful 
intestinal bacteria, so overcoming the effects of an excessive 
protein putrefaction, which is apt to take place when the 
diet contains a disproportionate amount of protein. 



564 ACUTE AND CHRONIC INFECTIONS 

Carbohydrate also has still another important function in 
fever in that it reduces the tendency to acidosis; always an 
additional burden in fever when it develops secondary to a 
low carbohydrate ration. 

When we come to discuss the actual constituents of fever 
diet, we have to take into consideration the usability of the 
various food elements. 

Carbohydrates. — These may be given in considerable 
amount up to 300 gm. (10 oz.) or more per day, depending 
on the patient's ability to take them without causing indi- 
gestion, beginning with less amounts and gradually increas- 
ing up to the limit. 

The forms of carbohydrate that appeal to the patient may 
be used, provided there is no special contra-indication present 
from the special fever to be fed; cereal gruels, toast and 
crackers, sago, tapioca, arrowroot and cornstarch. If amyl- 
aceous dyspepsia is present the cooked forms may be dex- 
trinized by the use of commercial preparations of diastase, 
such as takadiastase (10 to 15 drops added to a portion of 
cooked cereal kept at blood heat for fifteen minutes is usu- 
ally sufficient) or some of the malted foods may be used, 
such as malted milk, Mellin's food and malted breakfast 
food. Besides these we may use the various sugars in addi- 
tion to the maltose preparations already alluded to, princi- 
pally lactose and cane-sugar which may be added to cereal 
or milk feedings to advantage (see Typhoid Diets), and can 
also be administered with fruit juices, as in lemonade or 
orangeade. 

Protein. — The most easily available form of protein for ill 
people is some milk preparation given either as raw milk, 
skimmed milk, buttermilk, ripened milk, whey, Martin's 
milk, yoghurt, junket, boiled milk, soured milk, koumyss, 
matzoon, zoolak, cream, Delafield's mixture, peptonized 
milk, or citrated milk (made by adding 1 or 2 grains of sod- 
ium citrate to each ounce of milk). It may also be modified 
by the addition of water, Vichy, lime water, thin gruels, 
milk soups, cream, (lactose or cane-sugar) . In some invalids 
the mild cheeses are entirely allowable and constitute a 
palatable change from the usual routine ; for this purpose 
pot cheese, cream cheese and cottage cheese are principally 
useful. At most, probably not more than 3 or 4 pints of 
milk preparation should be given daily. This amount of 
milk represents approximately 60 to 80 gm. protein, fat and 
carbohydrate with a total caloric value of 960 to 1280 cal- 
ories, not, of course, sufficient for complete nutrition. It 
is posssible in many cases to give even 5 or 6 pints of milk in 






FEVER 565 

the day, but such a large bulk of food is apt to disturb diges- 
tion and result in an undue amount of feces with the added 
danger of gastro-intestinal disturbance. If greater caloric 
value is needed than that furnished by the 3 or 4 pints of 
milk daily, it is better to bring up the total fuel requirements 
by the addition of carbohydrates and fats. 

Next in value to milk come eggs as a protein supply for the 
sick. These are capable of preparation in so many forms 
that although patients tire of an excess of eggs, still a good 
amount of protein may be given by varied combinations; 
furthermore the fat of the yolk is one of the most readily 
assimilable fats that we have. Many patients have an idea 
that eggs do not agree with them and make them bilious 
(whatever that may be), but as a matter of fact there are 
exceedingly few persons who cannot take eggs in some form, 
the fallacy of their contention, is shown by the fondness of 
these same people for custards, either baked or frozen. 
There are, of course, a very few people who cannot take eggs 
on account of an anaphylactic reaction caused by protein 
poisoning, but fortunately this is an infrequent occurrence. 
Among the many preparations of eggs suitable for sick people 
may be mentioned boiled, poached, scrambled, coddled, raw, 
beaten up with milk and flavored with sherry, brandy or 
fruit juice; as custard — baked or frozen— egg whip, egg-nog, 
egg a la Swisse (baked with a little cheese over it). 

Meat protein, except in the form of broth is ordinarily 
omitted from the fever patient's diet, but if the appetite is 
good and the temperature low, a little beef may be given in 
the form of scraped-beef sandwiches. Broths of all kinds or 
meat jellies are freely allowed and although of little food 
value are distinctly useful for their appetizing qualities, the 
patients often relishing other foods better if they are allowed 
broths. 

For the same reason beef juice is often used, besides which 
it also has a slight stimulating effect upon the circulation. 
This is particularly seen in children who after beginning beef 
juice may pass a more or less excited, sleepless night. For 
the most part glandular meat preparations are by common 
consent left out of the fever patient's diet, although sweet- 
breads are allowed early in convalescence. The high per- 
centage of purine bodies in these foods form an objection in 
that their excretion is an unnecessary and additional burden 
to the kidneys. Oysters, if small, are often well borne and 
patients may be given certain kinds of fresh fish; cod, hali- 
but and bass, boiled or shredded, if they wish. As a matter 
of fact few ill fever cases like the "fishy" taste of this form 
of protein. 



566 ACUTE AND CHRONIC INFECTIONS 

Fats. — The simplest and most easily digested fats are those 
in natural emulsion, e. g., egg yolk and cream. Next in 
order is fresh .butter. Fat from meat or fish is much less 
easily digested, although there seems in certain cases to be 
an exception in favor of crisp bacon fat. From these forms 
of fat one can easily supply the dietary requirements. 

Beverages. — Beverages form a most important part of a 
fever patient's daily allowances and should receive careful 
attention. Most fever subjects crave water and take it 
liberally, but occasionally, a very ill patient or one in de- 
lirium cannot ask for water, so that the nurse must be on 
the lookout to supply a minimum of from 1500 to 2100 c.c. 
(50 to 70 oz.), fluid in twenty-four hours or in certain cases 
even more. This allowance may be made up of plain water, 
Vichy, tea, coffee, milk, cocoa or water flavored with fruit 
juices, lemons, oranges or grape juice. If milk, in an allow- 
ance of 3 pints per diem, representing 1500 c.c, forms the 
principal food, additional water should be given; at least 
up to 500 to 800 c.c. or more. 

Intervals of Feeding. — Ordinarily a two-hourly period is 
most convenient for feeding and agrees with the majority of 
patients, giving water in some form between feedings. There 
are cases in whom a three-hour period is better borne or 
even hourly feedings may at times be necessary. 

In prescribing an actual diet for fever patients the exact 
character of the food to be given will depend upon the type 
of fever, whether part of a short or prolonged illness and 
upon whether the fever is high or low. In general the short 
infections may be fed more or less according to the patient's 
appetite, while those with long-continued and high tempera- 
tures must be amply fed, the food for the most part being 
of a liquid or semisolid character. 

The routine for this is perhaps best exemplified by the 
typhoid diets (q. v.) the caloric value of which may be 
increased at will to meet nutritional demands by addition of 
either more or other food-stuffs, a good working rule being 
to furnish 1.5 to 2 gm. protein and 30 to 45 calories per kilo 
of body weight, the latter being increased still further if 
necessary, the patient's weight in health being taken as the 
basis of reckoning. Where no contra-indications exist it is 
possible in most cases of fever to give some soft solid foods 
chosen largely from the carbohydrates. 

Alcohol. — The use or necessity for alcoholic beverages in 
fever is a much-discussed question and must be answered 
from the stand-point of, first, necessity and second, exped- 
iency. On the first score, viz., that of necessity, the pendu- 



TYPHUS FEVER 567 

lum has swung far away from giving alcohol as a routine in 
fever and as an essential part of the diet, so much is this the 
case that one has only to consult the commissary depart- 
ment of any large hospital to note the comparatively small 
amount of alcohol now in use. While alcohol is ozidized in 
the body and to some degree can take the place of fat in 
sparing protein, it causes surface dilatation of the vessels 
and some loss of heat possibly from a half to one degree in 
moderate dosage, so that its food value is thus promptly 
nullified. Secondly, expediency. The use of alcohol de- 
pends somewhat on the patient's former habits, if a regular 
alcohol user, a moderate amount may be given at first, grad- 
ually diminishing it, as many patients who have used alco- 
hol freely develop delirium tremens if it is withdrawn quickly, 
particularly in fever. On the other hand, ordinarily it is not 
necessary but may do good in the typhoid state with a brown 
dry tongue, dry skin and subsultus; under these conditions 
3 to 6 ounces per day of good whiskey or brandy may prove 
very beneficial, otherwise it need not be used except possibly 
as a mild stimulant to the appetite or occasionally to flavor 
foods. When real stimulation of the heart is needed it is 
much better accomplished by other drugs. Abroad we still 
find wines ordered much more freely than on this side of the 
water, but even there the routine use of alcoholic beverages 
in fever is not practised as it formerly was. 

During convalescence the diet may be increased as rapidly 
as the appetite and digestion warrants, using soft solids such 
as farinaceous dishes of all sorts, scraped beef, fish, soft 
green vegetable purees, wine jelly, ice-cream, custards and 
gradually back to a normal dietary with due regard to any 
possible complications, such as nephritis or any sequelae of 
the fever. 

TYPHUS FEVER. 

In the United States this disease is seldom met with except 
in the milder form, as in Brill's disease, which is really a mild 
typhus. Abroad, however, and especially during wars, ty- 
phus is often met with in its severe forms, and while diet 
does not play the nice part that it does in typhoid it is equally 
necessary to keep these patients nourished to the limit of 
their capacity, digestively speaking. They can take all the 
foods recommended for typhoid in the high calorie regimen, 
and using good quantities of food prevents undue loss of 
weight which if well digested certainly helps the patient to 
fight the disease and renders convalescence shorter. In 
addition to the usual typhoid regimen one may use soft 



568 ACUTE AND CHRONIC INFECTIONS 

solids more freely, depending upon the patient's appetite. 
Chopped meat, puree vegetables, eggs in any simple form, 
cereals, ice-cream, blanc mange, and jellies, may be used to 
advantage. 

During convalescence the foods should be increased in 
variety and quantity just as rapidly as the patients will take 
them. Alcohol may be used at any stage but it is not es- 
pecially useful unless there is a failure of appetite, dry tongue 
or a typhoid state when a moderate amount of good whiskey 
or brandy, well diluted, is advisable. 

TYPHOID FEVER. 

With the advent of antityphoid innoculation this disease 
bids fair to be largely overcome, but until this is more univer- 
sally adopted typhoid will be endemic in this country and we 
shall have need for a proper treatment of the disease. In 
this treatment diet holds the first place in importance and 
while America has been blameworthy in its former careless- 
ness of typhoid it has happily been the pioneer in feeding 
these patients on scientific and rational lines, thus in some 
way making atonement. Indeed it is interesting to look 
through the Index Medicus on this topic and find that 
practically all the literature on advanced feeding during the 
past few years has been contributed by American physicians. 

Older Diets. — There is little use in taking up the reader's 
time with a discussion of the older methods of feeding where 
only milk, or milk, eggs and broth have been used, for these 
methods have been entirely discredited and although these 
articles still form a part of most typhoid dietaries, their 
inadequacy, when given alone, has been proven beyond a 
doubt. It would hardly seem necessary to urge practioners 
to feed their fever patients more liberally in the light of the 
generally diffused knowledge on the subject were it not for 
the fact that some of the older medical authorities, who are 
hardly to be equalled or excelled in the matter of clinical 
observation and diagnosis, are so hopelessly incomplete when 
they discuss the diet of this disease, as e. g., one standard 
text-book recommends a diet which allows 39 to 54 gm. pro- 
tein and furnishes 675 to 1000 calories, certainly insufficient 
if 'one wishes to maintain even approximately a nitrogenous 
equilibrium and body weight. 

Modern chemistry has taught us that the efficiency of 
human digestion during fever is reduced not more than 5 to 
10 per cent., and that the flow of the digestive enzymes is 
little, if any, interfered with, provided the organism as a 



TYPHOID FEVER 569 

whole, is properly nourished. Carlson, however, of late says 
that in forms of sufficiently high temperature all types of 
gastric secretion, continous, psychic and hormone are depressed 
or at times completely abolished. If the pancreas and in- 
testinal enzymes are not interfered with too much, digestion 
of properly prepared food will proceed practically normally 
as is seen in gastric achylia from other causes. Here then is 
the key-note of feeding these cases; that they shall be suffi- 
ciently fed in order to prevent malnutrition. It is to be 
hoped that we shall see no more sunken and hollow-cheeked 
typhoid cases reminding one of the Cuban reconcentrados 
or subjects of the Indian famines. 

The object sought in these cases is to prevent loss of body 
protein and weight as nearly as possible on the principle that 
a starving organism, of whatever degree, is not the best pos- 
sible fighting machine. It is not always possible or even 
best to attempt to attain these objects in certain cases, as 
there are unquestionably individuals who cannot take the 
large amounts of food necessary to accomplish this end and 
we must be content on account of an irritable stomach, com- 
plications, etc., to come as near this as possible. Each case, 
however, should be nourished to the limit of his or her capacity. 

Bacteriological and Physiological Basis for More Liberal 
Diets. — The older clinicians were temperamentally just as 
generous as those of the present day and only fed sparingly 
because they concluded that food was incompletely absorbed 
under such conditions as exist in the intestines of typhoid 
cases. Du Bois 1 has made a study of food absorption in 
typhoid on patients who were receiving large amounts of 
food and has found that absorption in these cases is little 
altered from the normal and draws the following conclusions, 
based on careful analyses to wit : That typhoid fever patients 
can absorb carbohydrates and proteins in large amounts 
and as well as normal individuals. Early in the disease the 
absorption of large amounts of fat does not seem quite as 
complete as in normal individuals. Late in the disease 
enormous amounts of fat can be absorbed (up to 327 gm. per 
day in Du Bois's cases.) 

Here then we have a catagorical reply to the question of 
absorption of food in typhoid, so that from this point of view 
one would no longer be justified in withholding a liberal diet. 
Having established this fact, it would be fair to ask in what 
proportion should the food elements be given, i. e., the pro- 
tein, carbohydrates, fats; to this question the bacteriologist 
and physiologist have also brought a definite reply. 

1 Med. Surg. Report Presby. Hosp., New Vork, 1912, p. 175. 



570 ACUTE AND CHRONIC INFECTIONS 

Carbohydrates. — Physiology has shown that carbohydrates 
spare both protein and fat, so that the diet rich in carbohy- 
drates is capable of preventing loss of body protein, if given 
in sufficient amounts, without crowding the consumption of 
protein above the average amount. This is in the face of a 
pretty active catabolism and Folin 1 showed that in starva- 
tion nitrogen metabolism can be reduced one-third by the 
use of carbohydrates. 

Then, too, carbohydrates are completely oxidized into 
water and C0 2 neither of which products cause, in elimina- 
tion, any strain or irritation to organs whose functions are 
already somewhat impaired by a parenchymatous degenera- 
tion accompanying any high temperature. 

They also found that "the greatest amount of heat pro- 
duced by any patient was 48 calories per kilo a day, the 
majority giving off about 35 calories. On this basis the 
high calorie diet gives 1000 to 2000 more calories than are 
expended in twenty-four hours and if the patients do not 
receive this, they lose both nitrogen and weight; later in the 
disease the excess is used in storing fat." It can therefore 
be seen that carbohydrates should form a considerable pro- 
portion of the typhoid's dietary. 

From the bacteriological point of view Kendall 2 tried two 
diets on cats, one protein and one carbohydrate, alternating 
biweekly. It was found that "the intestinal flora can re- 
spond in two ways: First, the flora may become dominantly 
proteolytic, then fermentative as the diet is changed, and 
second, in addition to alternations in bacterial types certain 
organisms can actually change their metabolic activities to 
accommodate themselves now to a protein now to a carbo- 
hydrate regimen. These changes consist essentially of alter- 
nations between proteolytic and gas-forming bacteria on a 
protein diet and acid-forming bacteria on a carbohydrate 
regimen. The absence of carbohydrate prevents the develop- 
ment of the acid-forming bacteria on a protein diet and the 
excessive amounts ol acid produced by the fermentation of 
sugar inhibits the growth of the proteolytic and aerogenic 
forms in the carbohydrate regimen. " 

The character of the food taken in alters the bacterial 
flora of the alimentary canal and the toxins as well. 3 If an 
•excess of carbohydrates is given the bacteria grow tremen- 
dously, but after a time they manufacture that which in- 
hibits their own further growth and the specific bacterial 

1 Am. Jour. Physiol., 1905, p. 66. 

2 Jour. Am. Med. Assn., lvi, 1084. 
^Interstate Med. Jour., 1913, xx, 413. 



TYPHOID FEVER 571 

toxins are less potent than when the bacteria are grown on 
protein alone. "The splitting products which the bacteria 
elaborate from carbohydrate are comparatively non-toxic to 
the human economy." u On the other hand, when the pro- 
tein predominates in the food and there is a small. amount of 
sugar present the bacteria grow luxuriantly, manufacturing 
an extremely potent, specific toxin and produce from the 
proteins splitting products which are toxic when absorbed 
from the alimentary canal. Hence in conditions of intes- 
tinal infection, especially typhoid, carbohydrates, should con- 
stitute a preponderating percentage of the food. " 

In the high caloric feeding cases tympanites was found to 
be due to an excess of lactose, diarrhea from an excess of 
cream in the diet. Torrey found that patients who were 
able to take large amounts of food without digestive disturb- 
ances possessed an intestinal flora largely dominated by the 
bacillus acidophilus and that patients with an initial putre- 
factive flora were capable of developing a favorable fermenta- 
tive flora with a disappearance of tympanities and diarrhea 
under the influence of diet. 1 The exceptions were among 
those who could not be liberally fed. Giving a culture of 
bacillus acidophilus was very satisfactory in tympanities 
and diarrhea. 

These quotations are given in full in order to bring home 
more sharply the necessity for placing a large reliance on 
carbohydrates in this condition, for most of the older dietaries 
were principally protein and a very small percentage ot fats 
or carbohydrates, scarcely more than that contained in milk. 

Metchnikoff has recognized these facts in his treatment of 
auto-intoxication. He reduces the amount of protein in the 
diet and increases the carbohydrates and feeds lactic acid 
bacilli to split up the sugar to form acid which will inhibit 
the growth of the ordinary proteolytic bacteria. 

Fats. — There is at least a theoretical objection to the large 
use of fats in the typhoid's diet in that they do not oxidize 
as readily as the carbohydrates and the intermediate pro- 
ducts of the fatty acids may some time cause serious trouble 
and produce an acidosis. In clinical support of this theory 
there is the well-known fact that obese persons stand typhoid 
very badly. Coleman, however, did not find this a practi- 
cal objection for after the early part of the disease the fats 
were as completely utilized as in the normal and in his series 
the fats furnish one-half the food energy. 

Proteins. — So far as the daily protein requirement is con- 
cerned, Shaffer and Coleman found that the best results in 

1 Jour. Am. Med. Assn., 1917, lxix, 329. 



572 ACUTE AND CHRONIC INFECTIONS 

sparing body protein were obtained on diets containing from 
62 to 94 gm. per day. This comparatively low quantity is, 
of course, only enough if sufficient carbohydrate is allowed to 
prevent unnecessary protein loss. 

Energy Requirement. — Coleman and Shaffer 1 calculated 
that the theoretical requirement of a typhoid case to be 40 
calories per kilo, i. e., approximately 3000 calories for a man 
of 150 pounds, "but they found that a diet furnishing this 
amount of energy was not sufficient to establish nitrogenous 
equilibrium." The best results in the maintenance of nitro- 
genous equilibrium were on 60 to 80 calories per kilo, i. e., 
4000 to 5000 calories per day. Patients of smaller stature 
requiring more energy per kilo than the average adult on 
account of the disproportion of surface area to weight. 

Having satisfied ourselves on the foregoing grounds that it 
is not only possible but distinctly advantageous to feed our 
typhoid cases liberally in the ways indicated, one naturally 
turns to the practical application of these principles as exem- 
plified in definite dietaries. One can and often must build 
up a suitable and particular diet for individual cases to meet 
the special conditions, but in general the following dietaries 
will be found helpful, as they fulfil the theoretical require- 
ments which have also been proven practical as well. The 
moderate use of protein in them and the large use of carbo- 
hydrates carries the patients through the period of greatest- 
danger without undue loss of body protein or weight. 

Results Obtained by Liberal Diet. — An answer to this 
question scarcely seems necessary to one who has read the 
fore-going pages but for those who want a definite statement 
to this end one can perhaps not do better than to quote 
Coleman's 2 analysis of 444 cases of feeding in typhoid cases. 
One-half on high caloric diet the other half on a diet of 
milk with few additional foods with a total caloric value 
of from 1000 to 1500 calories as follows: 

1. Duration. No difference, but long recrudesences, per- 
haps less common in high caloric (H. C.) patients than in 
low caloric diets (L. C). 

2. Condition of mouth was better in (H. C.) because 
patients mental condition was better. 

3. Nausea and vomiting in H. C. 19.3 percent. L. C. 22.6 
per cent. 

4. Tympanites in H. C. 67.5 per cent. L. C. 31.7 per 
cent.. 

5. Diarrhoea in H. C. 16.2 per cent. L. C. 48.6 per cent. 

1 Am. Jour. Med. Sc, 1912, p. 77. 

2 Jour. Am. Med. Assn., 1917, lxix, 329. 



TYPHOID FEVER 573 

6. Nervous symptoms in H. C. 3.6 per cent. L. C. 10.81 
per cent. 

Long delirium in H. C. 7.65 per cent. L. C. 38.3 per 
•cent. 

7. Perforation in H. C. .9 per cent. L. C. 3.15 per cent. 

8. Recrudescences in H. C. 6.7 per cent. L. C. 11.3 per 
cent. 

9. Relapses in H. C. 18. per cent. L. C. 14.9 per cent. 

10. Mortality in H. C. 8.1 per cent. L. C. 17.6 per cent. 

11. Complications. There were no complications in 81 
cases on H. C. 144 in 19 L. C. 

12. Range of temperature not affected. 

Before actual dietaries are discussed it must not be for- 
gotten that the early beginnings of the better feeding of 
typhoid cases dates back a number of years, and much more 
liberality was allowed by a few men of great clinical experi- 
ence like Kinnicutt and others, than by the majority of phy- 
sicians. It has remained, however, for Coleman, Shaffer 
and Du Bois to demonstrate conclusively the various theories 
in regard to this question and putting the whole subject 
upon the plane of scientific accuracy. 

Typhoid Diets. — Proteins. — Meats are better left out on 
account of the ease of putrefaction and renal irritation caused 
by the elimination of meat products. This is also true of all 
acute fibrile diseases. 

Eggs. — Egg albumen has been much used but the whole 
egg is best, the preferable form being slightly boiled. 

Fats. — Are best given as cream, butter and yolk of egg. 

Carbohydrates. — Starch without cellulose, crackers, toast, 
cereal, potato, rice, lactose. Fruit juices of all kinds. Apple 
sauce. 

Milk. — In typhoid, milk has been the subject of much 
discussion, but most patients can take it in some form and 
can digest it in quantities of from i}4 to 2 quarts a day. 

General Directions for Feeding. — The patient's appetite 
must, of course, be consulted and his taste for particular 
foods; above all great care must be taken to eliminate 
promptly any article that disagrees or causes persistent 
diarrhea, tympanites or vomiting. Feeding hours should 
be regular and the interval two or three hours. After a 
patient is first seen and his intestinal canal cleared it is well 
to begin on a very light diet for a day or two then gradually 
increase the amount of the daily ration until a full quantity 
of nourishment is taken. 

During the severest part of the illness feedings should be 
continued night and day, as a very ill patient usually is only 
;momentarily disturbed by taking nourishment. 



574 ACUTE AND CHRONIC INFECTIONS 

Among the diets suitable for the first days of the illness 
and in some cases continued much longer the liquid diets as 
given are most valuable and supply sufficient protein and are 
of fair caloric value 

Typhoid Fluid Diet (No. i). 

8 a.m. Milk and coffee, each 120 c.c. (4 oz.) ; 240 c.c 

(8 oz.). 
10 a.m. Milk, hot or cold, 240 c.c. (8 oz.). 
12 m. Barley gruel, 120 c.c. (5 oz.) with milk, 60 c.c. 

(2 oz.). 
2 p.m. Milk, 240 c.c. (8 oz.). 
4 p.m. Oatmeal gruel, 120 c.c. (4 oz.) with milk, 60 c.c.. 

(2 oz.). 
6 p.m. Custard with lactose (full cup) or ice-cream. 
8 P.M. Hot milk, 240 c.c. (8 oz.). 
10 p.m. Whey, 180 c.c. (6 oz.), with one whole egg and 

sherry. 
12 m. Oatmeal gruel, 120 c.c. (4 oz.); milk, 60 c.c. 
(2 oz.). 
2 a.m. Milk, 240 c.c. ( 8 oz.). 
4 A.M. Broth, 240. c.c. (8 oz.), with one egg. 
6 a.m. Milk, 240 c.c. (8 oz.). 
Values: Protein, 98 gm. (t>H oz.); fats, 52 gm. (1% oz.); 
carbohydrates, 150 gm. (5 oz.); calories, 1900. 

Typhoid Fluid Diet (No. 2). 

8 a.m. Milk and coffee, each 120 c.c. (4 oz.). 
10 a.m. Milk, hot or cold, 240 c.c. (8 oz.). 
12 M. Barley gruel, 120 c.c. (4 oz.), with milk, 60 c.c. 

(2 oz.). 
2 P.M. Junket with cane- and milk-sugar. 
4 p.m. Oatmeal gruel 120 c.c. (4 oz.), with milk, 60 c.c. 

(2 oz.). 
6 p.m. Junket with cane- and milk-sugar or ice-cream.. 
8 P.M. Hot milk, 240 c.c. (8 oz.). 

10 p.m. Whey, 180 c.c. with one whole egg and sherry. 
12 M. Oatmeal gruel, 120 c.c. (4 oz.) with milk, 60 c.c. 
(2 oz.). 
2 a.m. Junket with cane- and milk-sugar. 
4 a.m. Milk, 240 c.c. (8 oz.). 

6 A.M. Milk, 240 c.c. ( 8 oz.); 15 gm. i}/ 2 oz.) of lactose 
added to the four milk feedings. 
Values: Protein, 71 gm. (2}^oz.); fats, 81 gm. (2%oz.);. 
carbohydrates, 160 gm. (5j^oz.); calories, 2300. 



TYPHOID FEVER 575 

In certain cases we cannot increase the value of the diet 
beyond these limits and although a certain amount of weight 
is lost the condition of patients remains surprisingly satis- 
factory. After a few days, however, it is possible for the 
most part to steadily increase the quantity of food and this 
may be done by adding any one of the following articles either 
in addition to the diet already given or by replacing some of 
the feedings by these articles. 

Apple sauce, i ounce, 30 calories. 

Bread (slice) 1 ounce, 80 calories. 

Butter (1 pat), }4> ounce, 80 calories. 

Cereal (cooked), 1 heaping tablespoonful, 13^2 ounces, 50 
calories. 

Egg (one), 2 ounces, 80 calories. 

Egg white (one), 30 calories. 

Egg yolk (one), 50 calories. 

Lactose (1 tablespoonful), 1 ounce, 36 calories. 

Milk (whole), 1 ounce, 20 calories. 

Potato (whole), 1 medium, 90 calories. 

Potato (mashed), 1 tablespoonful, 70 calories. 

Rice (boiled to pulp), 60 calories. 

Cream, 20 per cent., 1 ounce, 115 calories. 

Modified Milk Fluid Diets and Food Combinations 

and Menus. 

For 1000 calories a day. calories 

Milk, 1 quart (1000 c.c.) 700 

Cream, 1 % oz. (50 c.c.) 100 

Lactose, 1 % oz. (50 grams) . 200 

This furnishes eight feedings each containing: 

Milk, 4 ounces (120 c. c.) 80 

Cream, 2 drams (8 gm.) 15 

Lactose, 1% drams (6 gm.) 24 

or 

Eggs, 2 150 

Lactose, 30 grams (1 ounce) 120 

Sugar, 25 ( 4 i ounces) ioo 

Milk, 800 c.c. {26% ounces) 560 

Cream, 30 c.c. (1 ounce) 60 

Lemon-juice, 30 c.c. (1 ounce) • 12 

Coffee, 150 c.c. (5 ounces) 00 

Tea, 150 c.c. (5 ounces) 00 

This furnishes seven feedings, one containing; 

Coffee, 150 c.c. (5 ounces) 00 

Egg, 1 75 

Lactose, 30 grams (1 ounce) 120 

Sugar, 5 grams 20 



576 ACUTE AND CHRONIC INFECTIONS 

One feeding containing: calories 

Tea, 150 c.c. (5 ounces) 00 

Cream, 30 c.c. (1 ounce) 60 

Sugar, 5 grams 20 

Four feedings each containing; 

Milk, 200 c.c. (6% ounces) 140 

One feeding containing; 

Egg, 1 75 

Sugar, 15 grams (J/£ ounce) 60 

Lemon juice, 30 c.c. (1 ounce) 12 

Water, 4 or 5 ounces ; ." 00 

For 1500 Calories a day; 

Milk, 1 Yi quarts (1500 c.c.) 1000 

Cream, 1 % ounces 100 

Lactose, 3^ ounces (100 grams) 400 

This furnishes six feedings each containing; 

Milk, 8 ounces (240 c. c.) 160 

Cream, 2 drams (8 gm.) 15 

Lactose Yi ounce (16 gm.) 64 

or 

Eggs, 2 150 

Lactose, 1 10 grams (sH ounces) 440 

Sugar, 25 grams ( 4 /s ounces) 100 

Milk, 800 c.c. (26% ounces) . . 560 

Cream, 120 c.c. (4 ounces) 240 

Lemon-juice, 30 c.c. (1 ounce) t . 00 

Coffee, 150 c.c. (5 ounces) 00 

Tea, 150 c.c. (5 ounces) 00 

This furnishes one feeding containing; 

Coffee, 150 c.c. (5 ounces) 00 

Egg, 1 75 

Lactose, 40 grams (1 % ounces) 160 

Sugar, 5 grams {y§ ounce) 20 

One feeding containing: 

Tea, 150 c.c. (5 ounces) 00 

Cream, 50 c.c. (1 % ounces) 100 

Lactose, 30 grams (1 ounce) 120 

Sugar, 5 grams (y 6 ounce) 20 

Four feedings each containing: 

Milk, 200 c.c. (6% ounces) 140 

Cream, 17 c.c. large tablespoonful 34 

One feeding containing: 

Egg, 1 75 

Lactose, 40 grams (1 Y ounces) 160 

Sugar, 15 grams (Y> ounce) 60 

Lemon-juice, 30 c.c. (1 ounce) 00 

Water, 4 or 5 ounces. 



TYPHOID FEVER hll 

For 2000 calories a day. calories 

Milk, \\i quarts (1250 c. c.) 1000 

Cream, 8 ounces (240 c.c.) 500 

Lactose, 4 ounces (120 grams) 500 

This furnishes sev^en feedings each containing: 

Milk, 7 ounces (210 c. c.) 140 

Cream, 1 ounce (30 c. c.) 60 

Lactose, Q/2 ounce) (18 grams) 72 

or 

Eggs, 2 150 

Lactose, 125 grams (4 ounces) 500 

Sugar, 15 grams i}/i ounce) 60 

Milk, 1000 c.c. (32 ounces) 700 

Cream, 240 c.c. (8 ounces) 480 

Cocoa, 5 grams 25 

Orange juice, 60 c.c. (2 ounces) 30 

Lemon juice negligible 00 

Coffee, 150 c.c. (5 ounces) 00 

This furnishes one feeding containing: 

Coffee, 150 c.c. (5 ounces) 00 

Egg, 1 75 

Lactose, 50 grams (1 % ounces) 200 

Sugar, 5 grams Q/j ounce) 20 

One feeding containing; 

Cocoa, 5 grams (J/jj ounce) 25 

Milk, 120 c.c. (4 ounces) 80 

Cream, 60 c.c. (2 ounces) . 120 

Lactose, 50 grams (1 ^ ounces) 200 

One feeding containing: 

Egg, 1 75 

Lactose 40 grams (\\i ounce) 160 

Sugar, 10 grams ( }4 ounce) 40 

Orange juice 120 c.c. (4 ounces) 60 

Lemon juice 1 to 2 teaspoonfuls 

Four feedings containing: 

Milk, 210 c.c. (7 ounces) 140 

Cream, 45 c.c. (ij^ ounces) 90 

For 2500 calories a day : 

Milk, 1 Yl quarts (2500 c. c.) 1000 

Cream, 8 ounces (240 c. c.) 500 

Lactose, 8 ounces (240 gm.) 1000 

This furnishes seven feedings each containing: 

Milk, 7 ounces (210 c. c.) 140 

Cream, 1 ounce (30 c. c.) 60 

Lactose, 1 ounce (30 grams) 144 

or 

37 



578 ACUTE AND CHRONIC INFECTIONS 

Calories 

Milk, iooo c.c (32 ounces) 700 

Cream, 240 c.c. (8 ounces) 480 

Eggs, 3 . 225 

Lactose, 165 grams (5^ ounces) 660 

Sugar, 40 grams (1 }i ounces) 160 

Bread, 1 slice, 30 grams (1 ounce) 80 

Uneeda Biscuit, 1 25 

Butter, 10 grams (3/3 ounce) 80 

Orange juice, 120 c.c. (4 ounces) 60 

Lemon juice (iJ4 ounce) 20 

This furnishes one feeding containing: 

Coffee, 150 c.c. (5 ounces) 00 

Egg, 1 75 

Lactose, 40 grams (1 }/% ounces) 160 

Sugar, 5 grams (>g ounce) 20 

Toast, 1 slice 8a 

Butter, 10 grams ( J^ ounce) 80 

One feeding containing: 

Egg, 1 75 

Lactose, 50 grams 1 % ounces) 200 

Orange juice, 120 c.c. (4 ounces) 60 

Sugar, 10 grams }i ounce) 40 

Lemon juice to taste. 
Water. 

One feeding containing: 

Egg, 1 75 

Milk, 200 c.c. (6% ounces) 140 

Cream, 40 c.c. (1 % ounces) 80 

Lactose, 25 grams (% ounces) 100 

Sugar, 5 grams ()4 ounce) 20 

Flavor with vanilla or nutmeg. 

One feeding containing 

Lactose, 60 grams (2 ounces) 240 

Sugar, 20 grams ( % ounce) 60 

Lemon juice 30 or 40 c.c. (1 or 1% ounces) 15 

Four feedings each containing: 

Milk, 200 c.c. (6% ounces) 140 

Cream, 50 c.c. (1 % ounces) 100 

For 3000 calories a day. 

Milk, 1 J4 quarts (1250 c. c.) 1000 

Cream, 1 pint (480 c.c.) 1000 

Lactose, 1 ounce (30 gms.) 1000 

This furnishes eight feedings each containing: 

Milk, 6 ounces (180 c. c.) 120 

Cream, 2 ounces (60 c. c.) 120 

Lactose, 1 ounce (30 gm.) , 120 

or 






TYPHOID FEVER 579 

Breakfast: calories 

Farina ioo 

Toast, I slice (30 grams before toasting) . . 80 

Cream, 100 c.c. (33^ ounces) 200 

Butter, 8 grams ( }4 ounce) 60 

Lactose, 40 grams (1 J^j ounces) 160 

Sugar, 20 grams ( % ounce) 80 

Coffee, 1 large cup or 2 small cups (300 c.c.) 00 

10-10.30 a.m.; 

Milk, 200 c.c. (6% ounces) 140 

Cream, 50 c.c. (1 % ounces) 100 

Dinner: 

Egg, 2 150 

Potato, medium, about " 100 

Bread, 1 slice, or roll, 1, about 80 

Butter, 30 grams (1 ounce) 234 

Apple, 1 medium (pared and cored) 75 

Sugar, 15 grams (}£ ounce 60 

3 to 4 p.m.; 

Tea, 150-200 c.c. (5-6 Yi ounces) 

Lactose, 50 grams (1 % ounces) 200 

Sugar, 5 grams (}i ounce) 20 

Cream, 50 c.c. (1 % ounces) 100 

Crackers, 3 uneeda, or 2 soda, toasted 75 

Butter, 8 grams (^ ounce) 62 

Supper: 

Rice, 25 grams (1 ounce) or farina, cooked with . . . 100 

Milk, 100 c.c. (3^ ounces) 720 

Toast, 30 grams (1 slice) . 80 

Butter, 8 grams (H ounce) 62 

Sugar, 5 grams (for cereal) (j^ ounce) 20 

Cream, 60 c.c. (2 ounces) 120 

Orange, 1 slice 100 

Sugar, 5 grams (with orange) 20 

Potato baked, served with butter, apple baked with 15 

grams sugar and about 8 grams butter. Some patients will 

eat more butter if unsalted butter is used in the diet. 
8 to 9 P.M. 

Cocoa, 5 grams (}4 ounce) 25 

Sugar, 10 grams (3^ ounce) . . '. . 140 

Milk, 150 c.c. (5 ounces) 105 

Cream, 30 c.c. (1 ounce) 60 

Lactose, 25 grams (Vq ounce) 100 

For 3900 calories a day 

Milk, 1 Yi quarts (1500 c. c.) 1000 

Cream, 1 pint (500 c. c.) 1000 

Lactose, 16 ounces (480 grams) 900 



580 ACUTE AND CHRONIC INFECTIONS 

Calories 

This furnishes eight feedings each containing: 

Milk, 6 ounces (180 c. c.) 120 

Cream, 2 ounces (60 gm.) 120 

Lactose, 2 ounces (60 gm.) 240 

Great care must be taken that the physician's enthusiasm 
for preventing loss of weight should not lead him to allow too 
great a jump in food quantities. 

The steps of increasing the amounts allowed must be grad- 
ual or almost certainly the digestive organs will be over- 
taxed and one must not forget that a patient's appetite is a 
fair indicator of the amount of food to allow. A high calorie 
diet forced down a patient with anorexia would most cer- 
tainly lead to a gastronomic fall. 

Typhoid Diet No. 3. 1 (Calories 3910) 

This diet is best in later stages or in convalescence. 
(9.00 a.m., 1. 00, 3.00, 7.00 10.00 p.m. and 1. 00 and 4.00 a.m.) 

Milk, 6 oz., total, 1260 c.c. ; calories, 860. 

Cream, 2 oz., total, 420 c.c; calories, 840. 

Lactose, 10 gm., total, 70 gm.; calories, 280. Total 
calories, 1980. 
At 11.00 a.m.: 

Egg (one), calories, 80. 

Mashed potato (20 gm.), calories, 20. 

Custard (4 oz.), calories, 250. 

Toast or bread (1 slice), calories, 80. 

Butter (20 gm.), calories, 150. 

Coffee. 

Cream (2 oz.), calories, 120. 

Lactose (20 gm.), calories, 80. Total calories, 780. 
At 5.00 p.m.: 

Egg (one), calories, 80. 

Cereal (3 tablespoonfuls), calories, 150. 

Cream (2 oz.), calories, 120. 

Apple sauce (1 oz.), calories, 30. 

Tea. 

Cream (3 oz.), calories, 180. 

Lactose (20 gm.), calories, 80. Total calories, 640. 
At 7.00 a.m.: 

Egg (one), calories, 80. 

Toast (one slice), calories, 80. 

1 Diets 3, 4 and 5 are taken from Coleman and Shaffer: Am. Jour. Med. Sc. 
1912, p. 77. 



TYPHOID FEVER 581 

Butter (20 gm.), calories, 150. 
Coffee. 

Cream (2 oz.), calories, 120. 

Lactose (20 gm.), calories, 80. Total calories, 510. 
Milk-sugar lemonade may be substituted for the milk mix- 
ture at 3.00 o'clock. 

Approximate values: Protein, 90; fat, 250; carbohydrate, 
318; calories, 3910. 

Typhoid Diet No 4. (Calortes 5580.) 

Milk, 5 oz., 9.00, 11.00 a.m., 1. 00 p.m.; 1200 c.c. ; calories, 
820. 

Cream, 2 oz., 3.00, 7.00, 10.00 p.m.; 480 c.c; calories, 
1440. 

Lactose, 15 gm., 1.00 and 4.00 a.m., 120 c.c; calories, 480. 
Total calories, 2740. 
At 11.00 a.m.: 

Eggs (two), calories, 160. 

Toast (2 slices), calories, 160. 

Butter (20 gm.),, calories, 150. 

Mashed potato (70 gm.), calories, 70. 

Custard (8 oz.), calories, 500. Total calories, 1040. 
At 5.00 p.m.: 

Egg (one), calories, 80. 

Toast (2 slices), calories, 160. 

Butter (20 gm.), calories, 150. 

Cereal (6 tablespoonfuls), calories, 290. 

Cream (4 oz.), calories, 240. 

Apple sauce (1 oz.), calories, 30. 

Cream (2 oz.), calories, 120. 

Lactose (20 gm.), calories, 80. Total calories, 1150. 
At 7.00 a.m.; 

Egg (one), calories, 80. 

Toast (2 slices), calories, 160. 

Butter (20 gm.), calories, 150. 

Coffee. 

Cream (3 oz.), calories, 180. 

Lactose (20 gm.), calories, 80. Total calories, 650. 
Approximate values: Protein, 122; fat, 293; carbohy- 
drates, 515; calories, 5580. 

Typhoid Diet No. 5. 

This furnishes 5570 calories and is perhaps less bulky. 
Milk, 5 oz., 9.00, 11.00 a.m., 1.00 p.m.; 1050 c.c; calories, 
700. 



582 ACUTE AND CHRONIC INFECTIONS 

Cream, 3 oz., 7.00, 10.00 p.m.; 630 c.c; calories, 1260. 
Lactose, 15 gm., 1.00 and 4.00 a.m.; 105 gm.; calories, 
420. 

At 11.00 a.m.: 

Eggs (two), calories, 160. 
Potato (mashed), 80 gm., calories, 80. 
Custard (8 oz.), calories, 500. 
Creamed chicken (1 oz.), calories, 50. 
Toast (two slices), calories, 150. Total calories, 950. 
At 5.00 p.m.: 

Toast (2 slices), calories, 160. 
Cereal (2 tablespoonfuls), calories, 290. 
Cream (2 oz.), calories, 120. 

Lactose (20 gm.), calories, 80. Total calories, 650. 
Use chicken only after convalescence is established. 
At 3.00 p.m., lemonade (lactose, 120 gm.). 
At 7.00 p.m. : 

Egg (one), calories, 80. 
Cereal (5 tablespoonfuls), calories, 250. 
Cream (2 oz.), calories, 120. 
Toast (2 slices), calories, 160. 
Butter (20 gm.), calories, 150. 
Coffee. 

Cream (2 oz.), calories, 120. 

Lactose (20 gm.), calories, 90. Total calories, 960. 
Approximate values: Protein, 106 to 115; fats, 212; car- 
bohydrates, 450 to 570. 

The larger numbers include chicken and lactose lemonade. 

Typhoid Diet without Milk. — Occasionally one undoubtedly 

meets with a case that cannot tolerate milk in any form, and 

in such substances Garton 1 had devised a diet leaving milk 

products entirely out which is about as follows: 

6.30 a.m. Cup of hot coffee, sugar, 2 drams (8 gm.) ; 

two slices of zweiback or toast, butter. 
8.30 a.m. One portion of oatmeal or Robinson's pre- 
pared barley, according to bowel conditions, 
with six buttered crackers, saltines. 
10.30 a.m. Six ounces of soup, various kinds (180 c. c). 
12.30 m. One medium-baked potato, mashed and pre- 
pared with butter and salt; two thin slices 
of buttered toast, hot, and one cup of hot 
weak tea with 2 drams (8 gm.), of sugar. 
2.30 p.m. Two teaspoonfuls of pudding, bread or tapioca; 
six saltines. 

1 Mil. Surg., Washington, 1912, xxx, 291. 



TYPHOID FEVER 583 

4.30 p.m. Two ounces (60 gm.), of rice, farina or cream 
of wheat mixed with 1 ounce (30 gm.), of 
butter and 4 drams (16 gm.), of sugar. 

6.30 p.m. Three slices buttered toast. 

8.30 p.m. Six ounces (180 c. a), of soup. 
The feeding periods may be made three hours if preferred 
by the patient. 

Diet in Typhoid Complications. — Intestinal indigestion, 
as exhibited by diarrhea or tympanites, must be treated 
etiologically so far as possible, cutting out of the diet any- 
thing which apparently disagrees, e. g., high fats may be 
shown by examination of the stools to produce fatty stools; 
great fermentation of the stool as tested by Einhorn's sac- 
charometer shows more than the normal production of gas 
in the tube (5 gm. of a normal stool should produce at most 
but a small bubble of gas in twelve hours' incubation). This 
would indicate either a reduction of the carbohydrates or the 
giving of some diastatic ferment (such as takadiastase) to 
assist the normal secretions. When the diarrhea or tym- 
panites is slight, or at most very moderate, it is possible to 
take time to make these more exact observations to arrive 
at a definite conclusion as to the cause of the disturbance; 
when, however, the tympanites develops rapidly and assumes 
menacing proportions, it is necessary to stop all carbohydrate, 
feeding at once. This condition is perhaps best practically 
combated by the giving of artificially ripened milk in small 
amounts, diluted or not, and as well, giving some reliable 
preparation of the Bulgarian bacillus. See page 569 (Bac- 
teriology in Typhoid). This is especially true and accom- 
plishes the desired lesult in most instances in which the 
patients have been fed with considerable lactose, but is 
almost equally efficacious in any form of carbohydrate fer- 
mentation. To some extent tympanites is due to lack of 
intestinal tone, quite as much or more than to actual fer- 
mentation, and when patients are properly nourished this is 
much less apt to be present. The use of broths, egg al- 
bumen in fruit juice and peptonized milk also come into 
consideration. 

Intestinal Hemorrhage. — The question always comes up 
in case of hemorrhage as to whether the patients should 
continue to be fed or not. If the hemorrhage is severe, so 
that the patient shows a constitutional reaction to it, by a 
drop in temperature, increased pulse, or evident anemia, it 
is safest to suspend all feeding for six to twelve hours, so 
that the whole canal can be put at rest by morphine and 
local applications. After this period, however, it is best to 
begin feeding again, using preferably thoroughly peptonized 



584 ACUTE AND CHRONIC INFECTIONS 

milk (peptonized one and a half or two hours), so that it may 
be absorbed high up in the intestine, still giving the lower 
ileum as much rest as possible. For slight hemorrhages 
there is no need of suspending feeding liquid nourishment, 
for the higher the nutrition is kept the better chance there is 
of there being little hemorrhage. 

Perforation. — At the first sign of perforation or its pre- 
cursor, local peritonitis, all feeding should be at once stopped 
and the medical man makes way for his surgical brother. 

Nausea and Vomiting. — This is an infrequent symptom, 
but should be treated from the dietetic point of view as laid 
down in the section on Irritable Stomach, p. 338. 

Water. — The feeding of typhoid would be incomplete with- 
out special reference to water-drinking. This is a most im- 
portant matter, and in the presence of a good circulatory 
system the amount taken should be large, 1500 to 2500 c.c. 
{i}4 or 2>£ quarts) per day or more. The removal of cer- 
tain metabolic by-products by the urine is distinctly favored, 
and, indeed, a favorable prognosis of a case is often in direct 
ratio to the urine output. 

Paratyphoid Fever. — The dietary regulations set forth for 
typhoid hold equally for paratyphoid fever. 

MALARIAL FEVER. 

There are no special indications for diet in this disease other 
than those which would be useful in any fever. The stomach 
is often irritable, and vomiting may be present, which may 
be increased by the quinine; if this is so the feedings indi- 
cated for an irritable stomach will be found useful, such as 
iced fluids in small amounts, DelafiekTs mixture, buttermilk, 
or buttermilk and Vichy. The gastric symptoms are rarely 
severe except at times in the estivo-autumnal type in which 
case the quinine must be given by hypodermic injection in 
appropriate solution. 

SCARLET FEVER. 

The diet in scarlet fever will be more fully discussed in the 
section on Pediatric Feeding in the Acute Exanthemata, and 
so far as adult feeding is concerned, much the same rules hold 
true. The patients should be fed on liquids for the first 
three weeks, of which milk modified upward, as in the ty- 
phoid milk diets, or downward, as in infant feedings, should 
form the bulk. Indeed, the liquid diets No. 1 and No. 2 



CEREBROSPINAL MENINGITIS 585 

as given under Typhoid would be distinctly useful, leaving 
out eggs in any form at first. After the first three weeks it 
is still necessary to be careful, by excluding meats and making 
the bulk of the foods from milk, gruel, cereals, custards, milk 
toast, etc. Should the kidneys become involved, diets 
suitable to the particular condition present may be found 
under the section on Feeding in Renal Diseases. 

SMALLPOX. 

No special diet is to be recommended for this disease, ex- 
cept that care should be taken during the initial period of 
fever to give sufficient calories and protein to prevent ema- 
ciation and loss of nitrogen, so that during the stage of sup- 
puration the patient may be kept in as strong and vigorous 
condition as possible. If this rule is carried out convales- 
cence will be shortened. When the fever is high, fluids or 
semisolids are best, adding soft solids as soon as the patient 
will take them. The milk, cream, and lactose formulae 
recommended for typhoid will be found convenient in making 
sure the patient gets the full allowance of food, for it is so 
easy to give a little broth, a little gruel, etc., now and then 
as the patient wants or will take it, and it will usually be 
found that the food value of such a diet is away below nutri- 
tional requirements. If this hap-hazard plan is followed 
the patients reach the stage of secondary fever from suppura- 
tion in an entirely unnecessarily depleted condition, vastly 
increasing the risks of this period. During the period of 
suppuration a return to liquids and semisolids must be 
made until the patients have strength to take soft solids, 
which may be given as soon as they will take them. In 
any event, water should be forced, and as much given at 
frequent intervals as can be taken, either plain, aerated, or 
flavored with fruit juices. 

CEREBRAL OR CEREBROSPINAL MENINGITIS. 

The diet best for these conditions follows the suggestions 
laid down for any fever, and consists of milk, gruels, lactose, 
milk and cream mixtures, as in typhoid fever or semisolid 
feedings, depending on the stage and variety of the disease. 
Great importance should be given to seeing that the patients 
take sufficient food to maintain their nutrition to as nearly 
a normal degree as may be, for, as has been pointed out re- 
peatedly in these pages, the better the nutrition, the better 
the disease-fighting qualities of the patient and the shorter 
the convalescence. So long as the patients are conscious or 



586 ACUTE AND CHRONIC INFECTIONS 

the swallowing reflex remains intact, fluids may be given by a 
feeding cup or spoon, but when coma becomes marked, or 
when it is not possible or practical for them to take the neces- 
sary food, recourse must be had to feeding by gavage, either 
through the mouth or nose. (See Gavage.) This should be 
done at regular intervals, but preferably not oftener than 
three or possibly four times in twenty-four hours, on account 
of the possibility of irritating the nose or throat by the 
passage of the feeding tube. 

If the digestion is poor, as it often is in children with these 
diseases, it may be advisable to predigest the food and give 
peptonized milk mixtures, and dextrinized gruels, adding 
other foods cautiously as the digestion improves. At times 
there is marked vomiting with these cerebral lesions, central 
in origin. It is wise to continue feedings regularly in spite 
of the vomiting, but in smaller quantities and at more fre- 
quent intervals, even down to half-hourly feedings. One 
can only determine by trial what the best interval for feed- 
ing is or the amount best suited to each case. 

If vomiting is increased by feeding it will then be neces- 
sary to omit mouth feeding and give what nourishment one 
can by rectum. 

MEASLES. 

The dietetic management of measles is for the most part 
that of any acute infection with fever. 

During the early stages nothing but liquid food should be 
given, together with such soft semifluid food as very soft- 
boiled egg, gruels, ice-cream, and meat or gelatin jellies 
giving as nearly the full caloric needs of the individual and 
as the appetite and digestion will permit. Since the eruption 
occurs on the mucous surface of the intestines, as well as on 
the skin, it is necessary to continue the semisolid or very 
soft character of the food as long as the skin eruption lasts 
(as the intestinal manifestations presumably remain about 
the same length of time), for it is quite possible by harsh or 
rough food to cause a breaking down of some of the areas of 
intestinal hyperemia, with consequent ulcer formation occur- 
ring secondarily. When the eruption has quite faded the 
diet may be steadily increased, returning to a normal diet 
early in convalescence. 

INFLUENZA (GRIPPE). 

The fever is the determining factor in this disease, and the 
patients may have any simple food that their appetite calls 
for, following for the most part the suggestions for feeding 



ACUTE ARTICULAR RHEUMATISM 587 

in fevers in which there are no special dietary indications. 
Since the manifestations of grippe are so varied, the diet may 
often be judiciously regulated in view of the particular or- 
gans affected, i. e., if the bronchial tree is principally involved 
the feedings should be regulated as in bronchitis ; if the gas- 
trointestinal form is present, due regard must be had to 
giving foods which are non-irritating to the stomach and 
intestine; particularly when there is vomiting, special care is 
needed. Under these circumstances, after a few hours of 
absolute gastric rest, one may give small amounts of butter- 
milk plain or diluted with Vichy. 

Delafield's mixture is often well borne when the patients 
can take nothing else. This consists of equal parts of milk, 
cream, and Vichy, with cerium oxalate gr. x, soda bicarbon- 
ate gr. xx, to each 4 ounces of the mixture. This should be 
given iced and in dram doses, at first every twenty to thirty 
minutes, increasing the amount gradually and lengthening 
the period. Sometimes iced malted milk will be retained 
or egg white with orange juice and powdered ice. After- 
ward the patient can take a more liberal diet of soft solids, 
then rapidly increasing to full diet. 

ACUTE ARTICULAR RHEUMATISM. 

During the past few years there has been a complete 
change in the conception of the etiology of this disease, the 
humoral theory, or, to put it in modern language, the theory 
of a disturbed body metabolism, as the cause of this disease 
has been entirely superseded by the proved infectious origin 
of much of this form of articular inflammation. Much ex- 
perimental work has been done to prove this latter, and num- 
erous observers have been able, by inoculation of animals 
with cultures from the throats of rheumatic patients to pro- 
duce attacks of joint inflammation which closely resemble 
the conditions found in this disease. The offending organism 
said to be responsible for this, and obtained from the tonsils, 
abscesses at the roots of teeth or, in fact, from any focus of 
pus infection, is a form of streptococcus. Whether there is a 
distinct strain of this bacterium which causes only rheu- 
matic lesions is exceedingly doubtful, as it is much more 
likely that it is one of the ordinary groups of streptococci, 
which, for some as yet unknown reason, has a predilection 
for the serous membranes of the body, particularly those of 
the joints and heart. By complement-fixation tests, Hast- 
ings claims to have differentiated several different strains 
of streptococci, all of which are apparently the cause of 



588 ACUTE AND CHRONIC INFECTIONS 

articular lesions at times. While therefore the humoral 
theory of this disease has been almost completely given up 
for a bacterial conception, it is still true that marked meta- 
bolic changes accompany the condition, as shown by the 
excessive acid perspiration and excessive urinary acidity, 
greater than that which is found in any other disease except 
possibly in a marked diabetic acidosis. It is not at all un- 
likely that the metabolic changes which often precede a 
rheumatic manifestation, may have much to do with the 
lowered resistance to the streptococci as is the case in rheu- 
matism. 

Diet in Acute Articular Rheumatism. — Diet therefore in 
this disease has a twofold relation, that to the general condi- 
tion of a bacterial invasion with resulting fever and other 
usual evidences of infection, and as well, to the metabolic 
changes which are probably, for the most part, secondary to 
the infection, or which at least accompany it and may stand 
in some etiological relationship, if only as a predisposing 
cause. So far as diet relates merely to the infection, we 
could stop at the general indications for diet in any fever, 
but the hyperacid condition of the excretions, notably the 
sweat and urine, must be taken into account in prescribing a 
suitable diet, and certain limitations are necessary on this 
account which would not otherwise be called for. During 
the first few days of acute fever after a thorough intestinal 
purge, the diet should consist mainly of milk products, and 
gruels, such as plain milk; milk, cream and Vichy; junket, 
Vichy and buttermilk; barley, rice and farina gruels may 
also be used. Water in large amount is grateful, either 
plain, as Vichy, and orange or lemonade made with very 
little sugar. Feedings should be given every two or three 
hours. 

After the first few days of acute illness, and when the appe- 
tite begins to improve, additions to the diet may be made of 
other cereals, stale bread and butter, fruits, especially 
oranges or scraped or baked apple, baked potato with cream 
or butter, then green vegetables. Lastly, egg and white- 
meated fish, such as cod, halibut and bass and chicken. 
These animal products should not be added until the tem- 
perature has been normal for ten days to two weeks, and 
then in only small amounts. Eggs are an earlier exception, 
however. 

The particular foods which should be avoided during a 
rheumatic attack, and for some time afterward, are meat 
soups and meats which, on account of their purine content, 
tend to produce acid and increase the uric acid in the blood. 



ACUTE ARTICULAR RHEUMATISM 589 

Sugar, except in minimal amounts, should be omitted from 
the diet on account of its tendency to produce acid fermenta- 
tion in the digestive canal. Tea and coffee are allowable 
only in great moderation, and well diluted with milk or 
water. Alcohol should be prohibited in any amount, and 
is not medically needed. Preserves, cake, and all such foods 
are to be avoided, as well as some of the hyperacid fruits, such 
as currants, gooseberries, and certain acid cherries. There 
is also a strong prejudice against the use of strawberries by 
rheumatic people not only during an attack but also for a 
long time afterward. The foundation for this prejudice is 
not clear, and is certainly not established by scientific analysis 
but rather from clinical observation. Like some other un- 
explained clinical data it probably has some sound reason 
behind it, and until proved innocent, strawberries should be 
omitted from the rheumatic's dietary. 

Subacute Rheumatism. — This stage of a rheumatic infec- 
tion should be treated dietetically on the same lines as a late 
stage of the acute process, and the same general rules apply, 
although here it is rather more necessary to see that the 
patients take a sufficient quantity of food to make up any 
loss occasioned by the fever, and a low diet during the most 
acute stage when the appetite is poor. The same necessity 
exists for abstinence from the acid-producing foods as in 
acute rheumatism, notably meat products, except occasion- 
ally; sweets and all indigestible foods in general should be 
avoided. 

Chronic Rheumatism {Chronic Infectious Arthritis), — This 
is a disease distinct entirely from gout, although after forty 
years of age there is often some difficulty in making a differ- 
ential diagnosis. This is usually facilitated by an estima- 
tion of the amount of blood uric acid, easily done by Folin's 
method. If the disease is not gout as shown by a normal 
blood uric acid (0.5 to 2 mg. per 100 c.c. of blood) the condi- 
tion is one of a chronic infection, with often the usual accom- 
paniments of anemia and malnutrition. The diet must be 
full and almost unrestricted, as the first indications are to 
nourish the patients satisfactorily and to increase their 
resistance to the infection. The only restrictions necessary 
are that meat and sweets should be taken in moderation. 

The question of using alcohol in these conditions often 
comes up, and it may be stated that alcohol is of no direct 
use except occasionally as an aid to the appetite, and except 
when needed for this purpose is better left out. Steady 
users of alcohol are more prone to infections than others, 
and infections have a stronger hold on even a moderately 
alcoholic subject than on an abstainer. 



590 ACUTE AND CHRONIC INFECTIONS 

In these patients who are subjects of this chronic infection 
all measures which raise resistance should be employed — 
fresh air, hydrotherapy, and forced feeding if necessary. 
In addition, finding the primary focus of infection wherever 
located, should be done, if possible, with its prompt removal, 
whether in tonsils, tooth root, pelvic organs, prostate, bone, 
etc. Often great assistance is rendered by autogenous vac- 
cines in clearing up the persistent symptoms, provided, of 
course, the focus of infection is found. 

Care should be taken not to produce indigestion by over- 
feeding or giving indigestible foods. Gastro-intestinal ca- 
tarrh must be avoided by a proper dietary. 

TETANUS. 

In tetanus it is not so much a question of what food we 
shall give, but the form in which it is given is most important, 
and of still greater concern is the method of feeding. In the 
early stages before the jaws are completely locked, semisolids 
and liquids may be given by mouth; but even at this stage 
any disturbance may precipitate a muscular spasm, and 
great difficulty is often experienced in getting sufficient food 
into the patients to nourish them. In the later stage, when 
the jaws are firmly locked, feeding may be done by putting 
the liquid food in the mouth between the teeth and inside 
the cheek, allowing it to get into the throat between the 
teeth or at the back. This is, of course, facilitated if any 
teeth are missing on one side. If this is not practical, liquids 
may be given by gavage through a nasal tube cocainizing 
the nose and pharynx by a nasal spray of a 2 to 4 per cent, 
solution. This may help to obviate the tetanic spasm so 
easily brought on by the least external irritation. 

If in spite of the cocain the spasms occur, it may be neces- 
sary to give a few whiffs of chloroform and then to put down 
a pint or more of concentrated food such as recommended for 
suralimentation (seep. 550). This can be done twice a day. 
Water may be given by mouth in one of these ways, or if 
reflex spasm is excited a continuous Murphy drip may be 
used. If the outcome is favorable, feedings can be given by 
mouth as soon as the jaws are unlocked, with a return to soft 
solids and normal food as rapidly as the patient's condition 
warrants it. 

YELLOW FEVER. 

Since the prophylaxis of yellow fever has been proved so 
sure and comparatively easy in the United States, only an 
occasional case imported into a new district is likely to be 



CHOLERA 591 

met with, although the southern countries suffer endemically 
from this disease. 

Most cases present three stages: the first stage of onset 
with fever, then a stage of remission, which may be perma- 
nent, or a third stage may set in of increased severity, which 
is characterized by the presence of black vomit. 

During the first two or three days no food should be given, 
but water must be supplied in large amounts; if vomiting 
begins early, so that nothing can be given by mouth, water 
may be given by rectum or even by hypodermoclysis, al- 
though this latter is seldom necessary. Fortunately the 
rectum and colon are quite tolerant in this disease, and after 
the onset may be regularly used for rectal feeding and the 
giving of water, so that although the full food requirements 
cannot be given in this way, sufficient food can be absorbed 
to materially help in maintaining nutrition. (See Artificial 
Nutrition.) 

If vomiting is severe it is useless to try to use mouth-feed- 
ing in any degree, but during the period of remission the 
attempt may be made to begin to feed by the mouth with 
the same foods recommended for feeding in cholera. 

If the patients proceed to the third stage with vomitings 
and diarrhea it is useless to try to give any food by mouth 
or rectum, but some relief may be obtained by enteroclysis 
of warm normal saline, and fluid can also be gotten into the 
circulation by hypodermoclysis or saline venous infusions. 
It is possible even in this stage that a little iced champagne 
or crushed ice with diluted brandy may be given by mouth 
or drop doses of pure carbolic acid in i or i^ ounces of water 
may be useful in quieting the stomach. In this condition 
little can be expected from food, and about all one can do is 
to keep the blood concentration as nearly normal as possible 
by the use of saline solution by one route or another. 

If this third stage is successfully passed and the patient is 
again able to take nourishment by mouth we can begin with 
egg albumen in dilute orange juice iced, koumyss or pep- 
tonized milk, malted milk, and cold bouillon, gradually 
returning to a diet of soft solids, and so gradually back to 
normal feedings. 

CHOLERA. 

The dietetics of cholera have to do with food in its relation 
to prevention and its nutritional role during the various 
stages of the disease. 

In every case of cholera the vibrio enters the system by 
way of the alimentary canal, there being no evidence that it 



592 



ACUTE AND CHRONIC INFECTIONS 



gains admission in any other way. Since this fact is firmly 
established the question of food and water prophylaxis, as in 
typhoid fever, assumes paramount importance and when- 
ever there is the least danger of infection all the rules of 
prevention must be applied to the food and fluid intake of 
all the residents in any threatened district. In order to 
accomplish this satisfactorily the following rules should be 
observed : 

Dietetic Rules in Cholera. — i. No water should be drunk 
unless sterilized by boiling; and even water for brushing the 
teeth and washing should be sterile. 

2. No fluids should be taken unless known to be sterile by 
virtue of previous sterilization, full pasteurization or with an 
alcohol content of at least 5 per cent., such as wines and 
liquors. Beer and ale unless made of sterile water should 
not be taken. 

3. All vegetables should be thoroughly boiled before using, 
nothing raw being taken. Fruits should be eaten only when 
cooked. 

4. Eating and cooking utensils must be washed only in 
boiling water. 

5. Ice made of distilled or boiled water alone to be used. 

6. The use of acidulated drinks is strongly advocated by 
most authorities, as acids are inimicable to the cholera vibrio. 
For this purpose lemonade made with the addition of 10 to 
15 drops of dilute sulphuric or hydrochloric acids is recom- 
mended. Davis recommends the following: Tartaric acid, 
15 gm. (yi oz.) in 1000 c.c. (1 quart) of sweetened sterile water 
to be drunk freely. 

All forms of indigestible foods or foods that are specially 
laxative should be omitted from the diet of everyone at a 
time of epidemic. After the disease has actually begun in 
anyone the diet in the early stage is of great importance, and 
should consist of meat jellies, gruels, peptonized milk or 
ripened milk, koumyss, zoolak, or buttermilk. 

In the middle stage of the disease, practically no food can 
be kept down or kept in long enough to do any good, as the 
vomiting and purging are extreme. The most that can be 
done during this stage is to give cracked ice, with or without 
a little champagne or diluted brandy ; even these are usually 
rejected, and we have to abandon attempts to feed by mouth. 
Some writers have advised rectal feeding, but there is little 
hope of success, as the peristalsis is so active that nothing 
will be retained long enough for absorption. It is, however, 
of great assistance in the algid stage to use thorough enter- 
oclysis two or three times a day, inserting the rectal tube 



CHOLERA 593 

six to eight inches and flushing out the bowel with large 
amounts of warm saline, using it hot, 105 to 108 . 

The usefulness of this is twofold, as it cleanses the bowel 
and offers an opportunity for the absorption of a fair amount 
of fluid. The use of the same acid drinks is recommended as 
long as the stomach will retain them. The most serious 
problem in these cases is that of supplying sufficient fluid to 
the tissues, as these patients tend to be desiccated, and many 
perish from this who, if not so handicapped, would be able 
to overcome their infection. In order to meet this demand 
for fluids on the part of the system, water, best in the form of 
normal saline, must be gotten into the circulation in every 
way possible, by hypodermoclysis or more rapidly by saline 
infusion ; the latter is more satisfactory, as it is so much more 
readily available to the dried-out tissues, and as much as 
2000 to 3000 c.c. (2 or 3 quarts) may be given at once and 
repeated when necessary. Sterile saline can also be given 
intraperitonially. At first the results from the use of this 
method seemed to promise a great reduction in mortality, 
as it is so promptly led to clinical improvement; while it 
does help, the eventual prognosis is not so greatly altered by 
the procedure as was at first hoped. 

Besides normal saline (0.6 per cent, salt solution), Hayem 
recommends the following intravenous infusion, \]4. or 2 
quarts at a time. 

Pure sodium chloride, 5 gm. (H ounce). 
Pure sodium sulphate, 10 gm. (J/£ ounce). 
Water, 1000 c.c. (1 quart). 

Since the successful use of human serum (ascitic fluid) by 
hypodermoclysis (see Artificial Nutrition) has been demon- 
strated, it would seem that this substance might be success- 
fully employed in cholera, thereby furnishing the body with 
fluid, some protein, and probably some natural antitoxic 
substances. So far as is known this method has not been 
used in cholera, but might well deserve a trial should an op- 
portunity present. When it is evident that improvement has 
set in, feedings may be begun of one of the liquid foods al- 
ready referred to, or peptonized milk. If diarrhea still per- 
sists, milk preparations, as a rule, are not so well borne, and 
recourse must be made to farinaceous gruels, at first prefer- 
ably dextrinized, later mixed with boiled milk or malted milk, 
meat jellies, clam broth, and oyster soup (served without the 
oysters) may all be used. Later, getting back to soft farina- 
ceous puddings, then other soft foods, carrying the patient 
through the convalescence on much the same diet as that 
used after typhoid fever. 

38 



594 



ACUTE AND CHRONIC INFECTIONS 



PERITONITIS. 

Acute Peritonitis. — This is always a surgical condition, 
and whether an operation is required or not will decide 
whether any form of diet is indicated. If operation is needed 
no food whatever should be given after making the diag- 
nosis; cracked ice may be allowed and water furnished by 
rectum either as repeated enemata, 4 to 6 ounces, every three 
or four hours, or a continuous Murphy drip will answer the 
purpose. 

If an operation must be postponed or is contra-indicated 
for any reason, Ochsner's treatment recommended for acute 
appendicitis is the best method of procedure (see p. 403). 
Lavage of the stomach may be performed if vomiting is 
present, and repeated often enough to keep this under con- 
trol. 

After operation, if there is a more or less general periton- 
itis, it is best not to give food by mouth for several days, 
water being supplied as for acute peritonitis, or even given 
by hypodermoclysis, if in spite of rectal salines the patients 
seem at all desiccated. After three or four days if the acute 
symptoms are subsiding, one can begin to give egg albumen 
with orange juice and water, whey, broths (without fat), 
then thin farinaceous gruels, buttermilk either alone or 
diluted with Vichy, then soft solids, and gradually build up a 
normal dietary. 

Chronic Peritonitis. — If this is tuberculous, or due to a 
low-grade infection from some one or other of the various 
bacterial groups, the diet may be full and nourishing, avoid- 
ing only indigestible foods or those likely to cause flatulence, 
such as sweets, potato, uncooked starches, vegetables of the 
cabbage family, onions, fresh bread, cake, pies, etc. Any 
increase of gas is sure to cause discomfort by pulling on adhe- 
sions. It is best to feed rather frequently and in moderate 
amount; the total caloric value of the food should be high. 

Aside from these restrictions the patients may eat what 
they like, but care should be taken by the physician in charge 
to see that they get their full quota of food in some form. 



CHRONIC INFECTIONS. 

The feeding of cases of chronic infections of all sorts is of 
great importance, for many times the possession of a good 
stomach and digestion will do more toward saving the day 
for the patient, who, for example, is the subject of a chronic 
sepsis, than anything that can be done medicinally. 



CHRONIC INFECTIONS 595 

The chronic tuberculous infections have been discussed 
under a separate heading, to which the reader is referred, 
and here we found that it was wise not to overfeed the patient 
too greatly. On the other hand, in practically all other 
chronic infections the chief indication is to give as much 
nourishing food as the patient can possibly digest. Due 
regard must, of course, be given to the individual digestive 
capacity, but within that there is no limit. Special atten- 
tion must be paid to the whims of appetite that are often 
the index of what will best agree, and as well, all food should 
be comparatively of slight bulk and concentratedly nourish- 
ing, i. e., large amounts of vegetable food and fruits should 
be avoided, as taking valuable room best reserved for real 
food. It is also often necessary to feed fairly high quanti- 
ties of protein, often up to 150 gm. per day or more, care 
being taken to keep the purine content rather lower than in 
a normal diet in order that the kidneys in particular shall 
not be irritated by the excretion of unnecessary amounts of 
uric acid and other xanthine bases. Often, however, pat- 
ients do well on less protein. 

In cases of any prolonged infection it is especially neces- 
sary to pay great attention not alone to the tastes of the 
patients but to the method of serving the food as well. Food 
appetizingly served is already half-eaten, to paraphrase a 
popular saying, and every effort must be made to stimulate 
a patient's desire for food. Under this latter would come 
into consideration the use of some form of alcoholic beverage 
taken with the meal. Depending upon the form of the in- 
fection, this is usually allowable, provided the excretory 
organs are in good condition, and only the lighter forms of 
drinks are allowed. An occasional glass of light-beer, claret, 
white wine, seltzer, or even a little whiskey well diluted 
with Vichy or other carbonated or plain water often adds 
very greatly to the ease with which food can be taken, and 
little or nothing extra to the work of the excretory organs. 

In order that there shall be no mistake in regard to the 
quantities of food taken, it is always best to reckon out the 
patient's needs calorically for their normal height and weight 
and then to add sufficient calories to cover the extra cata- 
bolism occasioned by the fever. Here we can again make 
use of Coleman's figures as given under Typhoid Fever, as 
he has shown that in order to keep these patients in nitro- 
genous equilibrium and body weight it is necessary to give 
them 40 to 45 calories per kilo, using considerable amounts 
of carbohydrate as the best sparer of body protein and fat. 
Of course it is not so necessary to keep to the limited range 



1 



596 



ACUTE AND CHRONIC INFECTIONS 



of food-stuffs that one must in treating an acute condition 
involving the integrity of the alimentary canal, as in typhoid 
but the greatest latitude may be granted, even including 
moderate amounts of meat, in spite of the presence of fever. 
Watch must be kept of the urine to see that there is no renal 
irritation or evidence of intestinal putrefaction, for in the 
presence of either, meat is best left alone. While a large 
amount of fruit and vegetable food cannot be taken, as al- 
ready observed, a moderate use of them is not forbidden, and 
fruit juices are particularly useful in assisting the intake of 
considerable amounts of water, always a necessity, and also 
in providing a certain amount of nourishment, as in the case 
of grape juice, one pint of which contains about 360 calories 
(von Noorden) taken with meals and diluted with some 
effervescing water; this latter is of really great assistance. 
One word in regard to the intervals of feeding. If a 
patient has sufficient appetite to take three main meals with 
an extra bite between meals and at bedtime, this is perhaps 
the best. As a rule this is not possible when there is con- 
siderable fever,, in which case one can give a feeding every 
two hours, and at each alternate feeding, i. e., every four 
hours, extras are given, such as soft solids, while at the two- 
hour intervals only a feeding of milk or gruel, etc., is used. 
Patients who cannot eat advantageously every two hours 
can be fed every three hours, making in this instance each 
feeding a soft and liquid feeding together. Each patient 
must be studied with this in mind in order to get in the 
greatest amount of food with the minimum of stuffing. 



RHEUMATOID ARTHRITIS. ARTHRITIS DEFORMANS. 

The etiology of this form of arthritis has been for a long 
time uncertain, some authorities classing it as a metabolic 
disease, others as a so-called rheumatic manifestation (infec- 
tion). The two most prominent theories which traced the 
trouble to a disturbed metabolism considered it as a form of 
gout from a faulty purine metabolism, and the other blamed 
a faulty calcium metabolism for the disease. Accordingly, 
as one considered it due to either of these disturbances, the 
diet was modified to meet the demands of gout, i. e., a low 
purine diet, or was ordered with a low calcium content. 
Calcium metabolism is a difficult subject, and it has never 
been clearly shown just what disturbance in the calcium ex- 
change existed in these cases, although a certain amount of 
retention seemed probable. 

On the basis of disturbed calcium metabolism, Bovaird 
designed the following diet, and in some cases seemed to get 
a certain amount of improvement; fancied or real. 



RHEUMATOID ARTHRITIS 597 

Low Calcium Diet; 

Bread, ioo gm. (3^ oz.). 
Potatoes, 100 gm. (3^ oz.). 
Apple, 100 gm. (33^ oz.). 
Sugar, 50 gm. (1% oz.). 
Butter, 50 gm. (i%oz.). 
Boiled meat, 250 gm. (83^ oz.). 
Fish, 100 gm. (3^ oz.). 

Calcium content, 0.315 gm. 
Protein, 80 gm. (2% oz.). 
Carbohydrate, 145 gm. (5 oz.). 
Fat, 100 gm. (3H0Z). 
Calories, 2000. 
As modern bacteriological methods have improved, in- 
creasing evidence has accumulated in favor of putting this 
disease among the chronic infections and today among most 
authorities this view is held. 

Why a chronic infection should result in deformed joints 
in one case and simply enlarged joints in another is not, of 
course, clear, but both forms, chronic rheumatism and arth- 
ritis deformans, have certainly been arrested by the removal 
of a focus of chronic infection with or without the assistance 
of autogenous vaccines. It is probable that all these cases 
fall into this class and that metabolic changes affecting pur- 
ines, calcium, or what not are secondary to the disturbance 
caused by the chronic infection. 

On this basis (which today seems fairly clearly proved) 
our dietary regulations have to do again, as in the case of 
chronic rheumatism, merely with the effects of a chronic 
infection, such as malnutrition, anemia, etc. On this account 
the diet should be nourishing and even stimulating, contain- 
ing a fair proportion of protein, much fat, and a considerable 
amount of carbohydrate, following largely the patient's 
appetite, with a due regard to the prevention of indigestion 
and obesity, both of which complications are rather prone 
to develop, since the patients are unable to take much exer- 
cise, or, in fact, in certain cases, any exercise. 

Because of a sedentary life these patients frequently de- 
velop a disturbance of their purine metabolism and have 
gouty manifestations added to their other troubles. It is 
best therefore not to give the upper limit of protein allowance, 
and in some cases, besides curtailing the purines, as in gout, 
the patients are rendered more comfortable by a rather low 
protein allowance, 50 to 60 gm. per day. Such a reduction 
is particularly advisable if there is a renal insufficiency, a not 
uncommon accompaniment of any chronic infection. 



598 



ACUTE AND CHRONIC INFECTIONS 



Except for the limitations noted, the diet may be practi- 
cally unrestricted, and those patients who are undernour- 
ished will be greatly improved by high calorie feeding, with 
some attention to muscular exercise by massage, vibration, 
and active or passive movements. Patients with arthritis 
deformans who by chance are obese and flabby will be helped 
by a diet which will remove the excess of fat, allow easier 
movement of the joints, and by attention to improvement in 
muscular tone by any one of the foregoing methods, provided 
the disability is too severe to allow of any form of natural 
exercise. The best means that Nature provides to fight a 
chronic infection is a properly nourished body, and the 
physician's first duty is to put his patient in the best possible 
condition of nutrition, omitting none of the ways or means 
that will accomplish this end. 



CHAPTER XXXI. 
DIET IN RELATION TO SURGICAL OPERATIONS 

It is only comparatively recently that anything like in- 
telligent or painstaking attention has been given to the diet 
in cases about to be operated upon, and although more or 
less care has been given in the postoperative period, it has 
been largely a hit-or-miss attention, and when most needed 
has received little or inadequate thought. This was notably 
true in the case of operative procedures upon the digestive 
tract, where, as one would naturally expect, diet must be of 
paramount importance. The gravity of this is being realized, 
and considerable advance has been made in feeding these and 
other cases with greater exactness and care. 

PREOPERATIVE DIET. 

Except for abdominal operations it makes little difference 
how the patients are fed before operation except that the 
diet should be simple and somewhat lessened in amount the 
day before. No food whatever should be taken later than 
twelve to fourteen hours before operation, and the bowels 
should of course, be previously thoroughly moved. 

In contradistinction to this is the care that should be given 
the diet in a patient about to have an abdominal section. 
Many cases who seek operation for some chronic trouble, 
but who are able to be about, reach the hospital or their 
home, after a busy day more or less tired, possibly somewhat 
nervous, go to bed, take a laxative and an enema in the morn- 
ing before operation and wonder (or their surgeon wonders) 
why there is so much postoperative abdominal distention. 
The result is readily explained by the fact that the patient 
is nervously tired, has had lack of dietetic oversight before 
operation and incomplete intestinal emptying. 

General Directions for Cases of Laparotomy. — Whenever 
possible, patients should go to bed or at least stop their ordi- 
nary activities and rest for from thirty-six to forty-eight 
hours before a major operation; twenty-four hours should 
be the minimum time. During the one and a half or two 
days the intestine should be kept fairly well cleared out by 
catharsis: castor oil, calomel (?), salts or merely cascara, 
aloes and salines. During the twelve to fourteen hours 

599 



600 DIET IN RELATION TO OPERATIONS 

immediately preceding the operation no food whatever 
should be taken, but water allowed freely until two or three 
hours before, after which nothing but mouth washes are 
permitted. The diet during this preliminary day or two 
should be of the simplest sort: eggs, broth, puree soups, 
soft cereals, possibly a little chicken or beef, toast or stale 
bread and butter, custard, wine jelly (with little sugar), rice 
pudding. Drinks as weak tea or coffee, water, Vichy. Milk 
is best not given except as buttermilk to those who like it, 
and then not over two glasses a day. Koumyss or ripened 
milk may be used instead, for none of these forms of milk 
yield the thick curds that raw milk does, and are therefore 
less disturbing afterward. During the six to eight hours 
immediately preceding operation, and after the catharsis has 
begun to be effectual, the patients are given two or three 
very thorough enemata, with the object of leaving the colon 
as nearly empty as possible. 

In spite of great preoperative care, some cases have a 
great deal of trouble afterward from gas, and many surgeons 
feel that the catharsis given, with the idea of clearing the 
intestine, results principally in irritating it, and while of 
course removing more or less of the intestinal contents, the 
food is hurried along without proper digestion, resulting in 
its fermentation with consequent gas production. These 
men advocate a light diet for a few days and merely cleans- 
ing the lower bowel by high enemata before operation. 

Diet Preparatory to Gastric Operations. — When there is to 
be an operation involving opening the stomach, Finney advo- 
cates rendering this organ as nearly sterile as may be by giv- 
ing only sterile food and drinks for a couple of days before 
operation, feeling that with a sterile intake the gastric juice 
will inhibit or kill the few organisms that do get in, so arriv- 
ing at the antioperative moment with what is practically a 
sterile stomach; even the feeding utensils are sterile. Anti- 
septic and sterile mouth washes are used to help to insure the 
object sought. This can be true only in the presence of a 
normal or hyperacid gastric contents; with a hypo-acidity 
or achylia, sterilization of the stomach contents is not a 
practicability. 

All this may result in reducing the danger of infection, but 
from a practical point of view it is difficult to believe that 
one can sterilize the buccal cavity and posterior nares. 
With ordinary care and a short fast before operation, with 
normal stomach secretion, the stomach is probably as nearly 
sterile as is necessary. 



POSTOPERATIVE DIET 601 



POSTOPERATIVE DIET. 



In the ordinary case of operation, not upon the head or 
digestive canal and appendages, the postoperative diet may 
be simply arranged. As soon as the patient recovers from 
the anesthetic, water may be given in sips, increasing as 
rapidly as the stomach will tolerate it. In case of continued 
vomiting it is often a good plan either to wash the stomach 
out with a stomach-tube or give one or two glasses of water 
all at once to act in the same way if it is vomited. After a 
few hours, feedings may be started by giving a little iced 
milk, koumyss, egg albumen, whey with orange juice, gruel, 
or broth, increasing to soft diet as rapidly as the patient's 
appetite demands it. 

Postoperative Diet for the Digestive Tube. — In operations 
about the mouth or throat, such as those for hare-lip, cleft- 
palate, and tonsillectomy, the diet must be exceedingly 
bland, only fluids being used, and usually iced food is more 
grateful than warm. Anything hot, of course, is distinctly 
uncomfortable or painful. 

For cleft-palate operations it is often necessary to train 
children to take their food from a spoon or dropper before 
performing the operation, for it is quite impossible for them 
to nurse from the breast or bottle, or in certain cases it may 
be even necessary for a time to feed by nasal gavage. 

Diet after Tonsillectomy. — At first small bits of cracked ice 
should be given to suck, and later iced milk is the best food, 
as it is absolutely non-irritating. Ice-cream is also grateful 
very early, but salty soups, gruels, or solid food should be 
postponed until the patient can swallow with comparative 
comfort. The sensations of the patient are the practical 
guides in feeding these people, and they may usually have 
what they like as soon as the throat is sufficiently healed. 
All rough, hard, scratchy, salt, acid, or peppery food should 
be given a wide berth. 

Postoperative Gastric Diets. — Not enough attention has 
been given to this subject by surgeons, and taking gastro- 
enterostomy as a typical gastric operation, we may describe 
its dietary treatment in detail, other gastric operations being 
similarly dieted, i. e., gastrostomy, pylorectomy, gastrec- 
tomy (partial), or for excision of ulcer or carcinoma. 

Diet after Gastro-enterostomy and Other Gastric Opera- 
tions. — It is only comparatively recently that any particular 
attention has been paid to the dietary treatment of patients 
following the operation of gastro-enterostomy, and on the 
whole it is still sadly neglected, the tendency of many sur- 



i 



602 DIET IN RELATION TO OPERATIONS 

geons, if not most, being to feed these patients, postopera- 
tively, very liberally and too soon. It has been the writer's 
experience to have known of cases, not yet two weeks post- 
operative given full hospital diet containing, as it does, 
rather coarse food and even corned beef and cabbage. Why 
there should be this postoperative dietary lack of care it is 
difficult to see, except that the results of some cases of gastro- 
enterostomy are so brilliant, despite this failure to give care- 
fully selected food, that those directly responsible for the 
diets ordered have been prone to think that the chances are 
equally good for all cases. This, however, is not at all true, 
and the percentage of cases who are only partially relieved, 
who have relapses or who are total surgical failures, is still 
too large to make it anything less than imperative to give a 
proper diet after this operation. Bearing on this point it is 
only necessary to quote the following figures to make it evi- 
dent that the results of operation are not always brilliant. 
Joslin 1 reports 82 cases of gastro-enterostomy done for gas- 
tric or duodenal ulcer, with the following late results: Cured, 
47 per cent.; unrelieved, 14 per cent.; relieved, 19 per cent.; 
died, 20 per cent. 

Peck, 2 in 74 cases of duodenal ulcer, found these late re- 
sults: Cured, 68.9 per cent.; died, 8.1 per cent. The rest 
improved, unimproved, or untraced. The results of gastric 
ulcer were a little less favorable. 

Records of the Presbyterian Hospital, 31 cases, one to six 
years postoperative, showed the following results: Cured, 64 
per cent.; relieved, 18 per cent.; unrelieved or died, 18 per 
cent. 

Kuttner, in 100 cases, cured 65 per cent.; relieved, 20 per 
cent.; unrelieved or died, 15 per cent. 

Martin and Carrol 3 report the operation unsuccessful in 45 
per cent, of cases observed by them. 

It is quite true that these results are being constantly 
improved by better technic and selection of cases, and, in- 
deed, if one could choose operator and case in every instance 
the resulting cures would probably be over 90 per cent. 
Since this is not possible, and one has to go by general aver- 
ages, the necessity of doing everything postoperatively that 
will tend toward improving the results, is sufficiently evident. 

The Diet. — For three days following the operation the 
patients should receive absolutely no food whatever. After 
the postoperative vomiting has ceased it is possible to give 

1 Jour. Am. Med. Assn., 1914, lxiii, 1836. 

2 Ibid., August 21, 1915, p. 660. 

3 Ann. Surg., May 15, 1915, p. 557- 



POSTOPERATIVE DIET 603 

-small amounts of Celestin Vichy, or ordinary Vichy with the 
sparkle out of it, i or 2 ounces every hour or two. Dur- 
ing this period extra water may be furnished the system by 
the Murphy drip or saline by the rectum may be given, 4 
to 6 ounces every three or four hours. For those not afflicted 
with severe thirst it is even better to withhold water by 
mouth entirely for one or two days, as in the von Leube 
gastric ulcer cure. After the preliminary three-day period 
of starvation the routine of the von Leube or Sippy's 
alkaline cure may be advantageously begun and carried 
through, possibly with a little greater rapidity than in 
the ulcer cure, depending upon the condition of the ulcerated 
area as determined at the time of operation. 

Von Leube Diet. 1 — When feedings are begun the second or 
third day the patients are given hourly 2 ounces of artificial 
Vichy, Celestin Vichy or alternating with 2 ounces of milk 
fully peptonized for two hours. Each day the milk is in- 
creased 1 or 2 ounces until 8 ounces are taken every two hours, 
and the Vichy increased 1 ounce each day until 4 ounces are 
taken every two hours. In this way fluids are given every 
hour, either Vichy or the peptonized milk. At the end of a 
week or ten days there may be added junket, fine cereal, 
milk toast, and many allow a soft-boiled egg. During the 
third week creamed fresh fish, such as halibut, or cod, mashed 
potato, cream of wheat, hominy, spaghetti, puree of vege- 
tables, and creamed soups. Farinaceous desserts, such as 
farina, tapioca, cornstarch, blanc mange, and custard. The 
patients will do well to avoid all alcoholic beverages for many 
months after the operation, but after the second week, tea, 
cocoa, or a little milk and coffee, if it agrees, may be taken. 
Everything must be done to avoid increased gastric acidity, 
and the free use of soda bicarbonate with calcined magnesia 
one hour after meals, the latter in amounts sufficient to keep 
the bowels regular, should be given to keep the acidity at the 
lowest point possible. 

It is absolutely essential for the best possible success of the 
operative results to insist on this routine or some equally 
conservative diet, for even though there is a new opening, 
unless the pylorus is occluded, the gastric contents are in 
part discharged through the pylorus and so pass over a duo- 
denal ulcer; and of course if the ulceration is on the gastric 
side of the pyloric ring the care in diet is even more self- 
evidently necessary. Then too, the edges of the new stoma 
are raw and irritated, and need protection, and great care 
in the prevention of further irritation which would naturally 

1 As modified by Dr. G. R. Lockwood. 



604 DIET IN RELATION TO OPERATIONS 



follow the use of injudicious foods. Looking upon the ulcer- 
ation as still potent for evil, in spite of the advantages de- 
rived from a gastro-enterostomy, the necessity for great care 
in diet cannot be too seriously impressed upon those having 
the management of such cases. 

When gastro-enterostomy is done for a benign stenosis of 
the pylorus, without ulceration, the need for care in the 
postoperative diet is still nearly as great on account of the 
condition of the edges of the new opening as already referred 
to; and a gastro-jejunal or jejunal ulcer is among the possi- 
bilities when unsuitable food is allowed too early or in too 
large quantities. All cases of gastro-enterostomy should 
abstain for months from all foods that are mechanically irri- 
tating (even after the period of very strict dieting is over), 
such as seeds, skins of vegetables or fruits, hard or rough 
foods, also from chemically irritating foods, as condiments, 
acids, heavy sweets, or those thermally irritating like hot 
foods or drink. 

The Absorption of Food. — The question of the absorption 
of food after gastro-enterostomy has been of considerable 
interest, for in the light of the changes affected in the food 
current it is interesting to know whether these patients ab- 
sorb their food as well as normal individuals, or whether the 
changed conditions result in a chronic, although possibly 
almost imperceptible, loss in food exchanges and consequently 
in nutrition, with a shortened longevity. This operation has 
not been done by modern methods long enough to speak with 
great weight as to longevity, but certainly children who have 
been operated on by gastro-enterostomy for congenital py- 
loric stenosis seem to grow and thrive as normal children do, 
and adults who have had the operation for ulcer or benign 
stenosis of the pylorus, if clinically cured, apparently are 
able to maintain normal nutrition, and no instance has come 
to the writer's notice of a case that has died later on after a 
clinical cure from any cause that could be due to malnutri- 
tion. 

In order to test the question from a metabolic stand-point 
a woman, two years after gastro-enterostomy and clinically 
cured, with both pylorus and new stoma patent, as proved 
by x-ray examination, was put on a modified Schmidt diet 
for a definite period of days and the nitrogen metabolism, fat 
absorption, and carbohydrate utilization were tested accu- 
rately, no deviation from the normal was found. 

The following tables are inserted to exemplify the same 
fact. It will be noted that among the cases in whom the 
metabolic experiment was made within a few days after the 



POSTOPERATIVE DIET 



605 



operation, the fat absorption was not as good as it was later 
This is probably the cause of the rather copious stools 



on. 



these cases of gastroenterostomy have in the weeks immedi- 
ately after the operation. 

Absorption after Gastroenterostomy. 





Time after 
operation. 


Diet. 


Fat 
absorbed 
per cent 


Fat not 
absorbed 
per cent. 


Nitrogen. 


Subject and conditions. 


Absorbed 
per cent. 


Not 
absorbed 
per cent. 


I. Non-malignant 1 . 
12. Non-malignant . 
3. Non-malignant . 
.4. Non-malignant . 


5 months 

/ 

24 
2 " 


Mixed 


923 
92.5 
92.7 

94-7 


7-7 
7-5 
7-3 
5-3 


91.0 

90.5 
92 . I 

927 


9.0 

9-5 
7-9 

7-3 



Absorption after Gastroenterostomy.- 



Condition. 



Time after 
operation 



and age. 



Fat. 



In food, 
gm. 



In feces, 
gm. 



Absorbed 
gm. 



Nitrogen. 



In 

food, 
gm. 



In 
urine, 1 Absorbed 
gm. gm . 



i. Obstructed 

pylorus 
2. Obstructed 

pylorus 
.3. Non-ob- 

structiYe 
hematemesis 

4. Obstructive 
dilatation 

5. Duodenal 
ulcer . 

6. Stricture of 
pylorus . 



20 days 


F., 


40 


69.0 


8.60 


87-5 


7.2 


7-5 


36 " 


F., 


52 


67.0 


17.70 


73-7 






11 " 


M. 


53 


118. 


1590 


88.6 


14 7 


11. 5 


18 " 


F., 


43 


122.5 


5.25 


95-7 






14 " 


M. 


4i 


210.5 


7.00 


93-5 






8 years 


M. 


68 


126.5 




91 .2 







97- 



93-9 



Finney's 3 Diet List following the Operation for Gastro- 
enterostomy. — First Day. — First twelve hours, nothing by 
mouth, nutrient enemata every four hours alternating with 
continuous salt solution by Murphy's method. 

First Day. — Second twelve hours, water in 4 c.c. (1 dram) 
doses by mouth every two hours. 

Second Day. — Increase water gradually up to 30 c.c. (1 
oz.) every two hours. 

Third Day. — Water, 30 c.c. (1 oz.) alternating with albu- 
men, 4 c.c. (1 dram); gradually increase quantities of each 
.until 

1 Paterson: Hunterian Lectures, Royal College of Surgeons of England, 1906. 
2 Camerson: British Med. Jour., 1908, i, 144. 
3 Am. Jour. Med. Sc, 1915, cl, No. 4, p. 474. 



606 



DIET IN RELATION TO OPERATIONS 



Eighth Day. — Any liquid, 60 c.c. (2 oz.) every two hours. 

Ninth Day. — Any liquid, 90 c.c. (3 oz.) every two hours. 

Tenth Day. — Any liquid, 120 c.c. (4 oz.) every two hours 
(discontinue rectal feeding). 

Eleventh Day. — One soft-boiled egg in addition to any 
liquid. 

Twelfth Day. — Two soft-boiled eggs in addition to any 
liquid. 

Thirteenth Day. — Soft diet. 

Fourteenth Day. — Soft diet. 

Fifteenth Day. — Very restricted light diet. 

Sixteenth Day. — Restricted light diet. 

Seventeenth Day. — Restricted light diet. 

Eighteenth Day. — Any digestible solid food. 

After the eighteenth day the following diet list may be 
gradually followed, and should be continued for at least four 
or five months: 

Soups, any light soup. 

Meats, any easily digested meats, as brains, sweetbreads, 
beef, mutton, lamb, poultry (best minced and taken either 
broiled or boiled). 

Fish, mainly the white variety, mackerel, bass, as well as 
oysters (boiled or broiled). 

Eggs in any form except fried. 

Vegetables, the easily digestible forms, best taken mashed 
or strained, as asparagus, spinach, peas, beans, potatoes, 
carrots, farinaceous food; any of the cereals; bread to be 
taken stale. 

Desserts, any of the light puddings. 

Fruits, mainly stewed. 

Fatty Foods, as cream, butter, and olive oil. 

Drinks, as milk, buttermilk, cocoa, carbonated mineral 
water, and plain water. 

The following foods Must be Avoided. — Rich soups, pork, 
fried foods, veal, stews, hashes, corned meats, twice-cooked 
meat, potted meat, liver, kidney, duck, goose, sausage, crabs, 
sardines, lobster, preserved fish, salted or smoked fish, sal- 
mon, cauliflower, radishes, celery, cabbage, cucumbers, sweet 
potatoes, tomatoes, beets, corn, salad, bananas, melons, 
berries, pineapple, hot bread or cakes, nuts, candies, pies, 
pastry, preserves, cheese, strong tea or coffee, alcoholic 
stimulants. 

Intestinal Lesions. — The diet for operations performed on 
the upper intestine follows the same routine as that advised 
for gastric operations. Those operations performed upon 
the lower small intestine or colon require less minute detailed 



POSTOPERATIVE DIET 607 

care, but the order of first liquids, then soft solids, solids, 
and mixed foods should be maintained, although the transi- 
tion from one to another may be more rapid than after opera- 
tion farther up in the digestive canal. 

Diet after Appendectomy. — No food should be given for 
from forty-eight to seventy- two hours postoperative. Water 
may be begun as soon as the nausea subsides — small amounts 
at first and increased as rapidly as the stomach will retain it. 
The first food should be broth, egg albumen, or Martin's 
milk, 1 then gruels, cocoa, soft cereals, and gradually back to 
a full diet. 

Diet in Certain Complications, following Abdominal 
Operations.— Vomiting. — After any abdominal section this 
symptom may become of paramount importance, taxing the 
surgeon's skill more than the original operation, for although 
comparatively little mechanical damage may be done to the 
wound by vomiting, the interference with nutrition, increase 
of shock, and desiccation of the tissues may all have exceed- 
ingly serious consequences. 

If after twenty-four to thirty-six hours the vomiting does 
not cease, or if it returns and increases on attempts to feed, 
special measures should be taken for its relief. It is practi- 
cally useless to persist in feeding if the vomiting continues, 
so that all fluids or food by mouth should be stopped at once. 
Any of the measures already recommended (p. 346) to con- 
trol vomiting may be tried, e. g., dram doses of chloroform 
water either alone or with 1 drop of 95 per cent, carbolic 
acid added with 1 ounce of water or the carbolic alone in 1 
or 2 ounces of water is often helpful. 

Elixir of menthol may be tried. A mustard leaf to the 
epigastric region, a small hypodermic of morphine, about 
Vn to Vs grain, sometimes helps. Cracked ice with cham- 
pagne may be given in small doses. Finally, if nothing else 
relieves intractable vomiting, the stomach should be washed 
out at regular intervals, not waiting too long before trying 
this. 

If the vomiting is of the ordinary postoperative type, not 
due to dilatation of the stomach, although persistent, and 
none of the procedures, including lavage, give relief, it is best 
to refrain from using the stomach at all for twelve to twenty- 
four hours and to feed by rectum as recommended in arti- 
ficial nutrition (p. 618), giving saline enemata of 4 to 6 
ounces (120 to 180 c.c.) between times, with the foot of the 
bed elevated on shock blocks. At least sufficient fluid can 

1 Martin's milk is prepared by making junket, separating the curd and whey, 
mashing the curd through cheesecloth or in a mortar and adding the whey. Pa- 
tients can sometimes take this, when they cannot take plain milk. 



608 



DIET IN RELATION TO OPERATIONS 



be given this way to insure the patient's tissues from be- 
coming dried out, and unless the rectum is intolerant it is 
seldom necessary to furnish water by hypodermoclysis. 
After a day or two of rectal feeding, another attempt may be 
made to give food in the form of iced liquids (such as egg 
albumen, with iced orange juice and water, partially pep- 
tonized milk, koumyss, buttermilk, gruels, puree, * or clear 
soups), then to soft solids, such as milk toast, soft cereals, 
custards, junket, scraped-beef sandwiches, and on to a more 
normal diet. It is not infrequently found that people will 
retain some food that they especially crave, although theor- 
etically it may be not at all what one would naturally advise ; 
and again some patients will retain solids or soft solids when 
they will not retain fluids, and it is always well to try this 
plan in case of need, using a little dry or buttered toast, 
zweiback, toasted cracker, or poached egg. 

Vomiting from Acute Gastric Dilatation, — If the vomiting is 
of dark brown or blackish fluid material in large amount, 
much more than the patient has taken by mouth, frequently 
repeated, it is probaby due to an acute dilatation of the stom- 
ach. The necessary and only relief for this is lavage repeated 
at first every two to four hours combined with a position 
of the patient which throws them on the right side, almost 
on the face ; this posture is to relieve the pressure on the duo- 
denum of the gastrohepatic ligament. When the fluid from 
the stomach is lessened in amount, the lavage can be done 
less and less frequently, and feedings may be begun which of 
course should have been stopped as soon as the diagnosis was 
made. These feedings should consist of some of the usual 
fluids recommended for irritable stomachs, e. g., egg albu- 
men, peptonized milk, whey, gruels all in small amount, 60 
to 120 c.c. (2 to 4 ounces), every two, three or four hours. 
Even after feedings are begun and all evidence of the gastric 
dilatation past, for a time the stomach should be washed out 
every morning. The feedings can be progressively increased 
in amount and quality as the patient improves, until soft 
and then full feedings are resumed. During the period of 
dilatation it may be necessary to furnish the patient with 
water either by the rectum or by hypodermoclysis. 

Prevention of Desiccation of the Tissues. — It not infre- 
quently happens that patients come to operation with the 
tissues comparatively lacking in water, either due to in- 
tractable vomiting or to the fact that water absorption has 
been interfered with by some stenotic condition of the upper 
gastro-intestinal tract or excessive diarrhea. Before pro- 
ceeding to operation this fact should be noted if present and 



POSTOPERATIVE DIET 609 

the fluid deficit made up in any way possible by mouth, 
rectum, or hypodermoclysis, and the operation postponed 
long enough to overcome this condition. 

The same state of affairs may develop after any severe 
operation in which vomiting is severe and always seriously 
complicates convalescence. It should not be permitted to 
escape notice or to continue. 

Dietary Measures in Postoperative Intestinal Distention. 
— This is due to a lack of muscular tone of the intestinal wall 
sometimes combined with an excessive intestinal fermenta- 
tion. If the intestinal paresis is severe it is difficult to over- 
come and forms a very serious complication. 

The indications under such circumstances are to omit all 
feedings, to give water by mouth, small repeated doses of a 
saline laxative, 4 gm. (1 dram), every hour in water, using 
Rochelle salts, sulphate of soda, or Epsom salts. A hypoder- 
mic of pituitrin often entirely changes the picture and may be 
repeated every two or three hours for a couple of days, if 
necessary, or less often as the case may be. Colon irriga- 
tions with hot saline or an enema of equal parts of milk and 
molasses, 120 gm. (4 ounces), may be given, followed by a 
high enema of soapsuds or plain saline, hypodermics of strych- 
nine sulphate, gr. 730 every three hours, and hot turpentine 
stupes to the abdomen. There is little chance of influencing 
the fermentation by drugs, but the giving of cultures of the 
lactic acid bacillus may be tried if the case is prolonged or 
subacute. 

When peristalsis is again established and the distention 
under control we may cautiously begin feedings. The par- 
ticular point which needs attention in the diet from this 
point on to further convalescence, is, that no easily fermen- 
table food should be given which might in any way increase 
the amount of intestinal gas. On this account all farina- 
ceous or carbohydrate foods should be omitted from the diet 
especially all sugars as tending to ferment. The feedings 
should be at first entirely protein, as egg albumen, bouillon, 
broth, meat jelly, then fats, as whole egg, clam juice with 
cream, then as conditions improve we may use some of the 
partially malted foods, such as malted breakfast food, boiled 
for two hours in a double boiler, toast or zweiback that is 
toasted to a hard crisp, which may be eaten with butter, then 
other cereals, and gradually increase the latitude of the feed- 
ings back to a carefully selected mixed diet. The feedings 
at first should be given about once in two or three hours in 
small amounts, increasing gradually to not over 120 c.c. 
(4 ounces) at a time. 
39 



610 DIET IN RELATION TO OPERATIONS 

This form of diet will usually be well tolerated, will not 
give rise to increased fermentation, and will be found useful 
in fermentative conditions of the gastro-intestinal tract aside 
from the postoperative period. 

Diet after Gall-bladder Operations. — When the gall-blad- 
der has been removed at operation the postoperative diet is 
that of any laparotomy, except that since there may be some 
temporary disturbance in the flow of bile it is well not to 
feed fatty foods except in very limited amounts. 

When the operation is merely a drainage, and for a time a 
sinus is left, the diet should be arranged with a view to fre- 
quent stimulation of bile production and to making it as 
fluid as possible. The first object is best accomplished by 
frequent feedings, since at each feeding the flow of bile is 
stimulated. The second indication is met by forcing the 
fluid intake up to 3000 to 4000 c.c. (3 or 4 quarts) of fluid in 
twenty-four hours. Since most of the bile passes out through 
the fistula during the early postoperative days it is necessary 
to sharply restrict all fat in the diet, for bile is essential for 
the proper emulsification and digestion of fats. The diet 
should therefore consist of easily digested meats, egg albu- 
men, clear soups, in fact any easily digestible protein. All 
farinaceous foods are allowed and with the proteins should 
form the bulk of the diet. Later, soft green vegetables and 
stewed fruits may be added . As the discharge of bile lessens 
one may begin to add fats to the diet in the form of thin 
cream, egg yolk, and crisp bacon. 

Diet after Operation for Hemorrhoids. — Since, as a rule, 
the bowels are confined for about five days after this opera- 
tion, the matter of diet is not unimportant, for at least the 
first few evacuations are painful. On this account it is a 
good plan to give a diet that will leave as little residue as 
possible even at the expense of complete nutrition not being 
maintained, so that there will be the least amount of fecal 
matter to be passed. This can be accomplished by feeding 
a diet principally protein and fat with the least amount of 
carbohydrate and no cellulose in the form of vegetables or 
fruits. 

To this end the following articles of diet are advisable. 
Tea, coffee, water, or a little wine if wanted, or dilute whis- 
key. Eggs in any simple form, meat without connective 
tissue, fish, oysters, clear soups, cream, butter, not over 
three slices of bread per day, fine cereals, such as farina or 
cream of wheat, jellies, desserts made from gelatin, and water 
ices. After the fourth day honey and molasses may be 
allowed in good amounts as laxative and assisting in soften- 



POSTOPERATIVE DIET 611 

ing the feces for removal by suitable catharsis when the 
proper time arrives. 

Constipating Diet. — For use after rectal and low intesti- 
nal operations. First four days applicable to hemor- 
rhoids and fistula-in-ano cases. In other cases fluids without 
milk may be continued until the fifth day. 

First Day. — Water. 

Second day. — Fluids without milk. 

Third Day. — Breakfast. — Farina with cream, soft egg, 
small slice toast, coffee. 
Dinner: Clear soup, small piece fish or lean meat, or 
4 raw oysters. A slice of bread and butter, gelatine 
desserts. 
Supper; Soft egg on toast, tea. 

Fourth Day. — Molasses or honey. (In cases other than 
hemorrhoids and fistula, do not add until two days 
before a bowel movement is desired.) 

Feeding after Intubation. — Since the introduction and 
general use of antitoxin in diphtheria, intubation is done less 
and less often, until now it is rarely necessary compared with 
conditions before the introduction of the serum. When it 
is done, however, the question of feeding the child becomes 
of great importance, and must be carefully carried out. If 
the food is given in the ordinary way after intubation, a cer- 
tain amount is quite sure to find its way into the larnyx and 
cause violent choking. This practically always happens at 
first; later the child learns to manipulate the food so that 
it will pass the tube opening. Frequently soft solids cause 
less trouble than liquids. When choking is a difficulty the 
child is laid on its back on the nurse's lap, with head hanging 
backward a short distance over the nurse's thigh; food is 
then carefully given by spoonfuls and increased as rapidly 
in amount as it can be taken; usually a few days or even a 
day of such feeding is all that is necessary, and the child 
can then learn to swallow without difficulty. 



CHAPTER XXXII. 

DISEASES OF THE DUCTLESS GLANDS. 

In relation to these diseases, diet plays a role of variable 
value — not so much in a curative or a prophylactic way, so 
far as the diseases themselves are concerned, as in the symp- 
tomatic dietetics in the effects of disease on these glands. 
Thus in the glycosuria accompanying acromegaly or exoph- 
thalmic goiter the diet is arranged largely on the require- 
ments of the individual with respect to this symptom. While 
this is all true, nevertheless a wrong diet is capable of greatly 
exaggerating the symptoms of some of the pathological con- 
ditions found in these glands, as, for example, the use of a 
stimulating diet in exophthalmic goiter is distinctly contra- 
indicated. As yet we know too little of the underlying 
causes of disturbances in the internal secretion of these glands 
to be able to apply to dietetics here the scientific criteria that 
are possible in some of the other diseases described in this 
book, and until the ways are cleared of all obstructions, we 
must do the best we can in selecting a diet on what is largely 
clinical experience. 



ACROMEGALY. 

The causes of diseases of the pituitary gland are by no means 
clear, and we can only know of their progress by the varying 
effects upon metabolism. If the whole gland is involved 
and hyperfunctionates, the increased secretion from the 
anterior lobe causes the well-known gigantism, that of the 
posterior, lobe leads to carbohydrate intolerance, with all the 
clinical manifestations of diabetes, as glycosuria, polydipsia, 
polyphagia, polyuria, and hyperglycemia. 

If the change is degenerative, with loss of function, it 
leads to an increased carbohydrate tolerance, with conse- 
quent increase in body fat often leading to obesity. 

In hyperpituitarism of the anterior lobe, feeding the dried 
gland has been tried, but with little success; the skeletal 
changes looking toward gigantism usually continue unchecked. 

When the hypersecretion affects the posterior lobe we must 
diet, as in diabetes, since there is diminished carbohydrate 
tolerance. 

If there is hypofunction of the anterior lobe we can give 
the dried gland by mouth but not with brilliant success. In 

612 



EXOPHTHALMIC GOITER 613 

the diet care must be taken that the carbohydrates are not 
taken in excess. A full mixed diet is best, combined with 
pituitary feeding, sometimes supplemented by thyroid ex- 
tract. 

ACUTE THYROIDITIS. 

The acute parenchymatous inflammation of the thyroid 
gland may be secondary to any severe acute infection, either 
general by the blood route or by local extension from some 
acute infection of the surrounding tissue. The swelling and 
tenderness of the gland tell the story, and it is then necessary 
to feed only the blandest sort of foods. All thyroid stimu- 
lants should be omitted, such as meat, soup or any meat 
products; oatmeal, too, should be forbidden. The acute 
inflammation is usually of short duration, unless due to an 
actual pus infection with loss of tissue which must then, of 
course, be treated surgically. 

If the swelling persists and evidence of subacute thyroidism 
develops or continues, the diet should be as advised for ex- 
ophthalmic goiter (q. v.). 

EXOPHTHALMIC GOITER. 

The etiology of exophthalmic goiter is still largely a matter 
of conjecture, but it is probable that in the last analysis we 
shall find that the cases may be classified as of toxic or neuro- 
genic origin. 

When the emphasis is put on the toxic basis we find not a 
few writers on the subject tracing the trouble to the gastro- 
intestinal canal, so that it is natural to find that here great 
stress is laid upon the importance of diet. If of neurogenic 
origin alone, diet will play an important role in the restora- 
tion of the organism to a normal basis. 

In any event the regulation of the diet certainly has much 
to do with the intensity of the symptoms, which can usually 
be diminished or increased by a proper diet or the opposite. 
Whatever the cause, one fact stands out with great distinct- 
ness, namely, that these patients are for the most part 
poorly nourished and in advanced cases are often emaciated. 
This is due to the stimulating catabolic effect of the exces- 
sive thyroid secretion, proved experimentally by obtaining 
the same effects on nutrition by the feeding of considerable 
amounts of dried thyroid substance of the sheep. Falta 1 
found that "as there exists an increased exchange in exoph- 
thalmic goiter it was believed it could be made up by an 

1 The Ductless Gland Diseases, p. 102. 



614 DISEASES OF THE DUCTLESS GLANDS 

abundance of albuminous food and he found that the giving 
of albuminous food increased thyroid function." Rugunger 
showed "that an almost albumin-free diet, very rich, how- 
ever, in carbohydrate, can depress the increased exchange 
to normal." When a large amount of nitrogen-free food is 
given, with a moderate quantity of protein, there is no fear 
of a loss of body protein. This reduces the hypersecretion 
of the thyroid gland and favors keeping intestinal putre- 
faction at its lowest level. The three chief indications in 
choosing a diet for these cases of exophthalmic goiter are: 

1. To avoid all stimulating foods and drinks. 

2. To give a diet which will prevent intestinal putrefac- 
tion, so far as possible or at least to keep it at a minimum. 

3. To increase the calories in the diet by an abundance of 
fat and carbohydrate foods, so that the albumin destruction 
is spared and the patients are made to gain in weight. 

Thomson 1 is a strong advocate of the intestinal putrefac- 
tive origin of this form of goiter and is very drastic in his 
elimination of all meat products, and prohibits butcher's 
meat and oysters, clams and lobsters, and limits the use of 
eggs to one a day, and advocates one of the fermented-milk 
preparations, such as buttermilk, artificially ripened milk, 
or peptonized milk; allows crusty bread, rice, cereals, ex- 
cept oatmeal, and vegetables except peas, tomatoes, beets, 
turnips, carrots, spinach, beans and asparagus. He also 
allows cooked fruits except raspberries and strawberries. 
The vegetables that he especially recommends are potatoes 
and string beans. Tea and coffee with milk are allowed in 
small amounts rather grudgingly. Non-oily fish, poultry, 
quail, and partridge are allowed. In Osier's Modern Medi- 
cine we find there is no objection to a moderate use of meat 
in these patients. 

Tibbies 2 says that "oatmeal and liver strongly stimulate, 
animal foods in general moderately stimulate, and a diet of 
milk, eggs, bread and butter, biscuits, etc., only slightly 
stimulate the thyroid gland and shows the way to the diet- 
etic treatment of exophthalmic goiter." 

The foods that contain considerable quantities of iodin 
are also to be avoided. (See Table, Part I.) 

The milk of thyroidectomized goats has been used and at 
times to advantage; its efficiency is said to be due to the 
absence of iodine. 

It will be seen from the foregoing quotations that it is no 
easy matter to choose foods that will keep these various 
things out of the diet, which for one reason or another are 

1 Thomson: Graves's Disease. 2 Food in Health and Disease, p. 489. 



EXOPHTHALMIC GOITER 615 

taboo with one or another authority, and still be able to 
nourish our patients; so that one must keep in mind the 
three cardinal factors already referred to and construct as 
nearly in accord with them as possible. 

Such a diet might well include foods as follows: fresh- 
cooked fruits, milk, one or two eggs per day, non-oily fish, 
as they are lowest in iodine, except codfish ; cheese, and fowl 
occasionally. Potatoes, carrots, endive, kidney beans, pump- 
kin, celery, onions, corn. Breads, biscuits, macaroni, rice, 
and all farinaceous foods except oatmeal. Sugars in mod- 
erate abundance unless there is an accompanying hypergly- 
cemia or glycosuria, both frequently present in the severe 
cases. These are all low in iodine, thyroid stimulating con- 
tent and putrefactive potentiality, and are of high caloric 
value. Alcohol should be absolutely prohibited. 

The final desideratum of furnishing a diet of high caloric 
value in order to improve nutrition and weight must be 
observed, as many of these patients have a continuous eleva- 
tion of temperature and must be overfed, much as we have 
seen to be essential in typhoid fever, if we wish to preserve 
or increase body weight, and a high calorie diet is necessary, 
feeding an extra one-quarter, one-third or even one-half the 
total calories needed for a normal person of the same weight, 
made up for the most part of the non-nitrogenous food-stuffs. 
The lower total quantities of nitrogenous foods are best, 
keeping the total daily intake down to 70 or 90 gm. protein. 

It is necessary, however, according to von Noorden, to 
avoid too rapid a gain in weight, as this throws too much 
work upon the heart, and has resulted in his experience, in 
circulatory collapse, as the strength of the heart does not 
keep pace with the increased weight. This is seldom a prac- 
tical danger, as it is usually difficult to get these patients to 
gain any considerable amount, except in the milder cases. 

Diet to Meet Special Indications in Exophthalmic Goiter. 
— When glycosuria is present it is necessary to reduce the 
intake of sugars first; if that does not eliminate the glyco- 
suria, then the carbohydrates have to be diminished, and if 
slight reduction in these does not result in a sugar-free urine, 
then it will probably be necessary to treat the case as true 
diabetes. This is fortunately rarely necessary, for, as a 
usual thing, while there may be a certain amount of hyper- 
glycemia present, particularly in the moderately severe or 
severe cases, even they often fail to show glycosuria, except 
occasionally a trace, unless an abnormal amount of carbo- 
hydrate is eaten. 

Diarrhea. — In the cases that are at all severe this is a very 
frequent symptom and must be treated intelligently from a 



616 DISEASES OF THE DUCTLESS GLANDS 

dietetic point of view. Naturally it goes without saying 
that whatever measures of rest or treatment tend to a gen- 
eral improvement of the patient will have a favorable in- 
fluence on the diarrhea. In spite of this there are cases in 
whom the diarrhea is an obstinate symptom. These patients 
have to be treated as one would a case of chronic enteritis, 
using the diet appropriate for that condition, and it is 
often a matter of great difficulty to get them straightened 
out and digesting sufficient food to maintain or increase 
weight. 

A combination of diet, general measures, and astringent 
medication, if necessary, are usually sufficient unless the 
case is too severe. 

Inanition. — Sufficient has already been said to indicate 
the needs of these cases. They must be given what amounts 
to a rest-cure with hyperalimentation principally of the non- 
nitrogenous foods, with due regard for all the factors already 
mentioned. 

MYXEDEMA OR CRETINISM. 

Since the condition of myxedema or cretinism is due to 
diminished or absent thyroid secretion, we find that clinically 
all that is necessary is to give these patients thyroid gland 
(dry extract) in order to bring about a condition normal or 
approaching it, so that diet plays little part. If, however, 
one wishes to produce the maximum effect of the artificially 
fed thyroid it would be well to reverse the diet as recom- 
mended for exophthalmic goiter, i. e., give all the thyroid- 
stimulating foods possible, such as meat and meat products, 
shell fish, oily fish, and other foods, which we found were 
of high iodine content. (See Exophthalmic Goiter). There 
is really little necessity for this, as the thyroid substance 
and a mixed diet are practically all that are necessary. 



ADDISON'S DISEASE. 

The loss of normal adrenal secretion in this disease results 
at first in a general lack of tone of the entire vascular and 
glandular system, with subsequent loss of flesh and asthenia. 
Tuberculosis of the adrenals is the usual cause of the disease, 
and although the accessory glands of the chromaffin system 
can, to a certain extent, compensate for the hypof unction of 
the adrenals, this is only true in the earlier stages; later on 
the dire results of the disease become evident. One must 
diet symptomatically very largely; if there is gastric dis- 
turbance the diets in use for irritable stomach or acute gas- 



ADDISON'S DISEASE 617 

tritis are of use. If there is diarrhea the diet for intestinal 
catarrh or chronic diarrhea becomes necessary. If there is 
merely a depressed digestion, with loss of appetite, one must 
feed as best one can, giving foods which are simple, very 
nourishing, and as concentrated as possible. As the thyroid 
stimulates the adrenals, some help may be obtained by in- 
creasing the thyroid secretion by a stimulating diet (such as 
that containing much meat or meat extract, soups and meat 
gravies) ; if this fails, thyroid extract can be given in rather 
small dosage, I or 2 grains, two or three times a day. In 
order to protect the gastro-intestinal canal from irritation 
it is essential that the food, besides being simple, concen- 
trated, and nourishing, should be soft and non-irritating, 
without gristle, skins, seeds, or uncooked cellulose. Mild 
stimulants to digestion are allowable in small quantities, 
bitter tonics before meals, a glass of sherry, port, beer, claret, 
or I ounce of whiskey well diluted with Vichy. Alcohol 
taken in any larger amount is contra-indicated. 



CHAPTER XXXIII. 
DIET IN MISCELLANEOUS CONDITIONS. 



ARTIFICIAL METHODS OF FEEDING. 

The problem of nourishing the body by other means than 
by mouth feeding has engaged the attention of clinicians and 
experimental workers for many years. The hope has been 
constantly entertained that some way could be found by 
which the entire physiological needs of the body could be 
met by introducing food by other than the natural route. 
In pursuance of this hope many methods have been devised 
to artificially nourish an individual, and the claim has been 
put forward by one or another investigator that a particu- 
lar plan has met or almost met the conditions. As labora- 
tory methods have become more exact, and these various 
ways of artificial feeding have been subjected to more search- 
ing analysis, the conclusion is inevitable that so far the most 
that can be done is to supply from 25 to 35 per cent, of the 
requirements of nutrition reckoned in necessary heat units, 
and w th the problem still unsolved as to how to furnish 
sufficient nitrogen to prevent the undue loss of tissue pro- 
tein. While this loss can be diminished by feeding peptones 
or amino-acids and carbohydrates, and possibly a little fat, 
not enough can be gotten into the system to do more than 
prevent the excessive nitrogen destruction, and no case 
has been permanently or completely artificially nourished. 

The conditions in which those various ways of feeding are 
useful are such as prevent the taking of food by the natural 
route, and include stricture of the upper alimentary canal 
from whatever cause, peptic ulcer and intractable vomiting, 
as in the vomiting of pregnancy, etc. 

The three methods by which artificial nutrition has been 
carried out are by rectal feeding, subcutaneous feeding, and 
intravenous feeding. 

Rectal Feeding. — By far the oldest and most serviceable 
method is that of rectal feeding and although, as already 
pointed out, it is not sufficient, it at least is of temporary 
benefit, and has a place of assured usefulness in dietetic 
therapeutics. As formerly practised, when all sorts of in- 
completely prepared foods were given by rectum, very little 
indeed was absorbed, and some years ago the author made 

618 



ARTIFICIAL METHODS OF FEEDING 619 

metabolism estimations on the absorption of a peptonized 
milk-and-egg mixture ordinarily used in the large hospitals. 
It was found that the loss of weight and nitrogen differed 
little from that seen in starvation, showing that almost 
nothing was absorbed. 5 This leads naturally to the ques- 
tion as to what the properties of the colon are in regard to 
normal functions. As an excretory organ, calcium, phos- 
phates, iron, and magnesium are excreted by the large in- 
testine. As a digestive organ, its role is a very minor one; 
in fact, almost nil, although enzymes from the small intes- 
tine do continue their action in the colon, and bacterial 
action is considerable on carbohydrates, protein, and cellu- 
lose. As an absorptive organ it is of very moderate useful- 
ness, although water and salts are well absorbed, amino-acids, 
monosaccharide sugars, and alcohol to a limited extent, and 
very much less and more slowly than by the small intestine. 
Fats are thought by some not to be absorbed at all. 2 

One element in those cases which have been reported suc- 
cessfully nourished for a considerable time by this method is 
probably that by reverse peristalsis, food has been carried 
through the ileocecal valve into the small intestine and there 
absorbed. This is not so improbable as it may at first sight 
seem, and when one considers how rapidly a bismuth enema 
is carried from the rectum to the caput coli, often within ten 
to twenty seconds, as shown by the use of the fluroscope. 
Therefore given a patent ileocecal valve, food might easily 
gain access to the small intestine and be there largely ab- 
sorbed. 

Of the food elements introduced in nutrient enemata we 
must discuss in more detail the fate of protein, carbohydrate, 
fats, alcohol, salts, and water. 

Protein. — The attempt has been made to introduce pro- 
tein in almost every conceivable form, as egg albumen, 
chopped meat and pancreas, beef juice, milk, peptone, pro- 
peptone, and amino-acids, with the result in general that the 
nearer the protein molecule approaches its ultimate fate in 
normal digestion, i. e., as amino-acids, the better is its ab- 
sorption, so we find peptone better absorbed than albumen, 
peptone than proteoses, and amino-acids better than pep- 
tones. 

There are two methods in vogue for determining the ab- 
sorption of foods introduced into the rectum, one, termed 
the ''washing-out" method, relies upon analysis of what is 
passed by rectum plus the washings from a high colon irri- 

1 Carter: Arch. Int. Med., April, 1908. 
2 Goodall: Boston Med. and Surg. Jour., clxx, 41. 



620 DIET IN MISCELLANEOUS CONDITIONS 

gation, and comparing the total nitrogen of these two with 
the nitrogen input. This is, of course, scientifically a very 
crude method, as there are many opportunities for error. 
The other, and more accurate method, depends upon die 
estimation of urinary nitrogen, comparing the intake and 
output, also in some cases calorimetry is used to determine 
the dynamic action of different food-stuffs. Edsall and 
Miller 1 found that although 47 per cent, of peptonized milk- 
and-egg mixture was apparently absorbed, the ethereal sul- 
phates in the urine during the period were so excessively 
high that the conclusion is inevitable that the apparent ab- 
sorption was really more due to a disappearance of the pro- 
tein by putrefaction, so that 47 per cent, is probably an 
entirely erroneous figure. 

Short and Bywaters 2 analyzed various reports of cases fed 
by the rectum, together with weight charts and urinary 
findings and concluded that: 

1. The daily output of urinary nitrogen from patients 
given enemata of peptonized milk and eggs (peptonized 
twenty to thirty minutes) showed that almost no nitrogen 
was absorbed, and the total nitrogen in the urine was little 
if any higher than that seen in the urine of fasting men or of 
patients who received only saline by rectum. 

2. Modern physiological opinion holds that proteins are 
absorbed principally as amino-acids, and the failure of the 
rectum to absorb ordinary nutrient enemata is largely due to 
the fact that peptones are usually given instead of amino- 
acids. 

3. Chemically prepared amino-acids or milk pancreatized 
for twenty-four hours, so that the amino-acids are separated, 
allows a much better absorption of nitrogen, as shown by the 
high nitrogen output in the urine. 

4. The low output of ammonia nitrogen shows that the 
high total nitrogen was not due to the absorption of putre- 
factive bodies when the amino-acids are used. 

So far, then, as protein absorption goes there is no doubt 
but that amino-acids produced chemically from beef, e. g., 
the preparation called "aminoids, " or milk pancreatized for 
twenty- four hours, i. e., until the casein is brought to amino- 
acid, is fairly well absorbed, but still not in sufficient amount 
to prevent a continuous negative nitrogen balance. The 
Boas and Riegal enemata of milk, egg yolk, wine and arrow- 
root, or Leube's pancreas, 50 to 100 gm. (1% to 33^ oz.). 
meat, 150 to 300 gm.; fat, 30 to 45 gm. (1 to 1 3^ oz.); water, 
150 c.c. (5 oz.), ground in a mortar and injected into the- 

1 Wisconsin Med. Jour., 1903, i, 87. £ British Med. Jour., 1913, i, 1361.. 



ARTIFICIAL METHODS OF FEEDING 621 

rectum, may all be said to be of little value and not worth 
using in the light of modern investigation, their use is 
mentioned only to be condemned. 

Fats. — There is great difference of opinion regarding the 
absorbability of fats by the rectum. Friedenwald and Ruh- 
rah believe that fat in emulsion, e. g., egg yolk is absorbed 
better than is usually believed and recommended the addi- 
tion of egg yolk to every enema. Short and By waters, on 
the other hand, conclude that very little if any fat is absorbed. 
Goodall thinks that some fat is taken up by the lymphatics 
but exceedingly little is absorbed. Taken all together there 
is little if any experimental evidence that fats are absorbed 
by the colon except possibly in minimal amounts and too 
little to be of any nutritive value. 1 

Carbohydrates. — With some of the carbohydrates, notably 
the monosaccharids, there is every evidence that the colon 
is able to absorb considerable quantities, and this class forms 
the backbone of rectal alimentation, provided it is not given 
in too concentrated a solution, for one of its disadvantages is 
the fact that it may cause rectal irritation, and one cannot 
foretell what strength of solution an individual rectum will 
tolerate. Boyd and Robertson found that %, of a 10 to 20 
per cent, solution of dextrose was absorbed to a total of 40 
to 50 gm. (i}4 or 1 % oz.) but decided that a total of 30 gm. 
(1 oz.) was less apt to cause pain and diarrhea. Either pure 
dextrine glucose or dextrose may be used. Goodall used 
500 c.c. (1 pint) of a 3 to 16 per cent, solution of dextrose 
and after five hours found 42 to 52 gm. (ij^ or 1 % oz.) was 
absorbed, with a 10 per cent, solution 157 to 163 gm. (5 or 
5^ oz.) was absorbed and with a 15 per cent, solution as 
much as 144 to 193 gm. was taken up, and he contends that 
the amount of sugar destroyed by bacterial action varies 
from 0.5 to 1 per cent. Many observers, however, find that 
the weaker solutions up to 5 per cent, are better tolerated, 
causing less rectal irritation. This latter may in part be 
due to the fermentation of the sugar which can be prevented 
by adding 1 part of thymol to 4000 parts of the solution. 
AVhen lactose was substituted for the dextrose it was found 
that the ammonia nitrogen in the urine rose rapidly, showing 
that it was not well absorbed. This did not happen when 
dextrose was used. The addition of absolute alcohol to the 
rectal feeding increases its food value, but care must be taken 
not to use strong solutions, as they promptly produce rectal 

1 There is apparently good reason to believe that animal fats of low melting- 
point such as cod-liver oil are absorbed by the skin and form one possible method 
of artificial nutrition, especially in infants, if the oil is well rubbed into the skin 
of axillae and groins where the glandular and lymphatic supply is rich. 



622 DIET IN MISCELLANEOUS CONDITIONS 

irritation. The following combination of dextrose, alcohol' 
and saline represents a serviceable feeding, supplying 555 
calories and will be absorbed approximately in eight hours. 
Dextrose, 50 gm. (1% oz.). 
Absolute alcohol, 50 gm. {1% oz.). 
Normal saline solution, 1000 c.c. (1 qt.). 

The same authority found that if large enemata with the 
same proportions of dextrose and alcohol were used absorp- 
tion was not so complete, and this was also true of enemata 
of the same size but of higher concentration. When this 
can be tolerated by the rectum it is especially useful in: (1) 
Simple exhaustion. (2) In certain septic conditions, especi- 
ally good for the heart muscle. (3) As an antidote to chloro- 
form and phosphorus poisoning or anything that causes fatty 
liver, as the fatty changes may often be prevented by giving, 
glycogen-forming material. (4) In diabetic acidosis and ace- 
tonemia. (5) After abdominal operations, particularly in 
undernourished or desiccated individuals. 

This enema may be alternated with milk pancreatized for 
twenty-four hours, or the dextrose and alcohol be added 
in 2 to 5 per cent, strength as follows: 

Dextrose, 20 to 50 gm. (1 % oz.) 80 to 205 calories. 

Alcohol, 20 to 50 gm. (1% oz.), 140 to 350 calories. 

Pancreatized milk, or commercial amino-acids, 1000 c.c. 
(1 qt.), 206 calories. 

Salt, 9 grn. 

This solution may be given in 250 c.c. (8 oz.) dose every 
four hours, and represents about 420 to 755 calories (1000 c.c. 
of peptonized milk, has merely the caloric value of the pro- 
tein for rectal feeding; the fat and lactose are probably 
little utilized). 

Hutchinson 1 recommends a solution of unboiled starch as 
unirritating and well absorbed, but does not present data 
which are convincing. 

Precautions in Rectal Feeding. — There are certain pre- 
cautions which must be observed if one expects to have suc- 
cess in rectal feeding, otherwise they will certainly not be 
successful : 

1 . The rectum must be kept very clean by a good irrigation 
of saline once a day. 

2. The food must be sterilized, the peptonized milk in par- 
ticular must be brought to a boil after peptonization is 
complete. 

3. When the rectum becomes irritated by using solutions 
which are too strong the strength must be reduced and the 
rectum given a rest of a few hours after a saline cleansing. 

1 Food and Dietetics, p. 519. 



ARTIFICIAL METHODS OF FEEDING 623 

4. All enemata should be given with the foot of the bed 
raised on shock-blocks and the patient should remain in this 
position for at least an hour after it. 

5. It may be necessary to add 5 to 10 drops of deodorized 
tincture of opium if the rectal irritability cannot be other- 
wise controlled. 

It -is often advantageous to give the dextrose solution by 
the Murphy drip, which is done by putting the solution at 
105 F. in an irrigator and keeping this warm by means of 
cloths wrapped about the apparatus, or by placing a lighted 
electric bulb in the fluid to keep up its temperature. The 
fluid flow is then regulated by a stop-cock or merely by 
pinching the rubber tube by an artery clamp so that the 
fluid will drip from 60 to 90 drops per minute. This can often 
be continued for hours, depending on the rectal toleration. 

Subcutaneous Feeding. — This division of artificial nutri- 
tion has engaged the efforts of many experimenters, but as 
yet the goal seems as far off as ever, for although it is possible 
to supply a certain amount of protein and carbohydrate and 
fat by the hypodermic route, the quantities are too small to 
be at all sufficient for nutritional requirements. This method 
is far less distinctly valuable than the rectal routine of feed- 
ing, but when for any reason it is impossible to use the rec- 
tum, it may be used to some, but, taken altogether, slight 
advantage. 

Protein. — Protein in many forms has been used, as egg 
albumen, peptone, alkali albuminate, and propeptones,but 
all these forms cause irritation, abscess and a breaking down 
of tissue besides setting up a renal irritation. 1 Experiment- 
ally it was possible in dogs by giving small repeated and in- 
creasing doses of skimmed milk peptonized one and a half 
hours to supply protein, so that the nitrogenous balance 
showed only a loss of 0.3 to 0.5 gm. per day, but for ordinary 
use milk peptone when injected hypodermically must be 
considered dangerous on account of its toxicity, and should 
not be used. 2 More promising was the use of blood serum 
or ascetic fluid given hypodermically, 3 and in this way a 
certain amount of nitrogen can be supplied to the system 
which is made use of. Blood serum contains about 1 per 
cent, nitrogen and ascetic fluid, 0.17 to 1 per cent., so it can 
be seen that in order to supply sufficient protein to maintain 
nitrogenous equilibrium even in Chittenden's low estimate 
of 0.12 gm. nitrogen per kilo daily, it would take for a man 

1 Gautier: Diet and Dietetics, p. 529. 

2 Carter: Arch. Int. Med., April, 1908. 

3 Carter: Am. Jour. Med. Sc, August, 191 1. 



624 DIET IN MISCELLANEOUS CONDITIONS 

of 70 kilos from 840 c.c. to 4200 c.c. of fluid depending upon 
whether blood serum or ascetic fluid were used, entirely too 
large an amount for practical daily use. A certain amount 
may be used, up to 300 or 400 c.c. daily, probably without 
detriment to the organism, and although this has not been 
used in such large amounts in man, larger amounts propor- 
tionally have been injected in dogs without seeming detri- 
ment, and nitrogen can be given to them in this way to a 
certain and often large extent which is absorbed, metabolized 
and excreted ; nevertheless, during the test periods there was 
always a negative N balance of from 0.04 to 4.35 gm. nitro- 
gen for a two- or three-day period, the starvation balance 
for two days being 3.83 gm. nitrogen. 

If serum or ascetic fluid is aseptically drawn it can be used 
without sterilization, but if there is any doubt it should be 
heated to 55 C, which causes it to become opalescent but 
not coagulated. 1 

Salter 2 injected 100 to 120 c.c. (3 J/£ to 4 oz.) of horse serum 
heated to 65 C. without albuminous coagulation, and noted 
that the nitrogen excretion in the urine was increased. 

Fats. — Comparatively little accurate experimental work 
has been done with the hypodermic injection of fats from an 
exact metabolic point of view, but it has been found that 
sterilized olive oil can be injected in amounts of 30 to 40 c.c. 
(1 or 1 yi oz.) daily, preferably 10 c.c. in three or four places, 
and that it is absorbed and metabolized is evidenced by the 
diminution in the excretion of nitrogen. In this way Hutch- 
inson believed he could supply 500 calories. There is no 
■doubt but that oil so injected is utilized, but the absorption 
is very slow, and its usefulness as a means of artificial nutri- 
tion is not at all clear. Subcutaneous injections of egg yolk 
with one-third its weight of normal saline, and strained 
through cheesecloth, have been given, increasing from 1 to 
10 c.c. given in the buttocks; although tried in children, its 
use has not been checked by careful observation, and is not 
to be recommended. 

Carbohydrate. — The one form of carbohydrate which has 
been successfully used by the hypodermic route is dextrose. 
Voit, 3 in 1896, used a 10 per cent, solution and found it could 
be injected under the skin without glycosuria, although it 
was too painful and caused too much infiltration of the 
tissue to be useful. Kausch 4 began with a 2 per cent, solu- 

1 Reinach: Berl. klin. Wchnschr. March 20, 1899. 

2 Guy's Hosp. Rep., 1896, liii, 241. 

3 Munchen. med. Wchnschr., August 4, 1896. 

4 Deutsch. med. Wchnschr., iqii, No. i, 8. 



ARTIFICIAL METHODS OF FEEDING 625 

tion of dextrose, using up to iooo c.c. ; if he used a stronger 
solution, 8 to i.o per cent., it was promptly excreted in the 
urine, but without renal irritation. He also observed that 
the poorer the patient's general nutrition was the better the 
sugar was borne. Gautier found that 60 to 80 gm. (2 or 2 J^ 
oz.) of glucose in 1000 c.c. (1 qt.) of water with 5 or 6 gm. 
salt added was well absorbed when given by subcutaneous 
injection, but even this is not sufficient to furnish more than 
a fraction of the normal requirements. 

Intravenous Feeding. — This has been tried with various 
foods, principally milk and sugar solutions. The method is 
of slight if any practical usefulness, although if it is necessary 
for quick action, Goodall advises giving an isotonic dextrose 
solution (5.4 per cent.) in Ringer-Loche solution intraven- 
ously. The following is the formula recommended, espec- 
ially for children. 

Dextrose, 55 gm. (ij^ oz.). 

Potassium chloride, 0.2 gm. (3 grains). 

Calcium chloride, 0.2 gm. (3 grains). 

Sodium carbonate, 0.1 gm. (13/2 grains). 

Aq. destil. q. s. ad., 1000 c.c. (1 qt.). 
Kausch recommends the following solution for intravenous 
use when necessary : 

Dextrose, 50 gm. {1% oz.). 

Sodium chloride, 9 gm. (J^ oz.). 

Adrenalin chloride (1 to 1000 sol.), 10 gtt. 

Aq. destil. q. s. ad. 1000 c.c. (1 qt.). 

Filter and boil and give intravenously twice daily. 
One cardinal rule in giving dextrose solutions either subcu- 
taneously or intravenously is that they must be given very 
slowly, as otherwise they are excreted by the kidneys with 
inadequate absorption. Woodyatt and Wilde 1 in some ex- 
periments on animals and later with human application, de- 
termined that a man of 70 kilos (154 pounds) at rest may re- 
ceive intravenously and utilize completely 63 gm. glucose 
per hour without showing glycosuria. This is equivalent to 
252 calories per hour or 6048 per day. The normal tolerance 
limit for glucose expressed as velocity is established, as these 
authors say, at close to 0.85 gm. of glucose per kilo (2.2 
pounds) of body weight hourly. This solution is given by 
a specially constructed apparatus by which the rate of the 
solution's flow can be accurately regulated. 

The giving of food solutions intraperitoneally has been 
tried but should not be used under any circumstances, as^ 
too little is gained and an added shock is put upon the sys- 
tem. 

1 Jour. Am. Med. Assn., December n, 1915. 
40 



626 DIET IN MISCELLANEOUS CONDITIONS 

To critically summarize these various methods of artifi- 
cial nutrition, it may be said that the rectal route is the only 
one that is so far at all clinically satisfactory and that by 
this means roughly one-third the caloric requirements may 
be given in the form of dextrose solution with a certain 
amount of protein in the form of amino-acids, and, of course, 
water and salts in entirely sufficient amount if the rectum 
is tolerant. If for any reason the rectum is not usable, a 
fair amount of nitrogen can be given by the hypodermic in- 
jection of serum or ascetic fluid and from 20 to 40 gm. of 
dextrose as a 2 to 4 per cent, solution and possibly 30 to 40 
gm. of fat as olive oil. Intravenously proteins and fat are 
not available, but a certain amount of dextrose can be given 
up to 55 gm. (?) in a 5 per cent, solution in Ringer-Loche 
fluid, although in either the subcutaneous or intravenous 
injection of dextrose a certain amount is apt to be lost through 
the kidneys unless given very slowly. 

DIET IN PREGNANCY AND ITS COMPLICATIONS. 

Many and varied have been the dietetic rules laid down 
for this condition, almost entirely founded on clinical experi- 
ence, or supposed experience, and in turn almost every form 
of food has been under the partial ban of exclusion. 

During the earlier months of pregnancy the appetite and 
ordinary metabolism need only be considered in choosing a 
diet, except when marked nausea exists. In the later months 
Cragin recommends giving meat not more than three times 
a week, and, since much depends upon the regularity of the 
bowel movements, some attention must be given to anticon- 
stipation elements in the diet; fruit, fresh, stewed or dried, 
and green vegetables, all in considerable amounts are very 
serviceable. In spite of such a diet most patients require, 
as pregnancy advances, some additional laxative substance 
or drug. 

Nausea and Vomiting of Pregnancy. — Some women are 
bothered by morning nausea or vomiting more or less during 
the first three or four months of pregnancy, in fact a certain 
amount of this is the rule, but after the fourth month the 
sensation generally disappears and the appetite, which has 
usually been poor or capricious during this period, returns 
to normal and may continue up to the end of the pregnancy. 
At times the nausea and vomiting are so extreme as to menace 
life and are presumably of toxic origin accompanying an 
acute yellow atrophy of the liver as postmorten examination 
in these fatal cases usually shows. There have been many 



DIET IN PREGNANCY 627 

theories advanced to explain the mild morning vomiting of 
pregnancy and the pernicious form but to quote an Editor- 
ial in the Journ. Am. Med. Assn., June 7, 1919, the theories 
advanced in explanation of these phenomena are unsatis- 
factory because most of them are at best only part of the 
possibilities presented by this particular type of nausea and 
vomiting. There are various factors which point to some 
metabolic factor in the origin of both the mild and pernicious 
form of vomiting. The ketonuria also present is an added 
indication of a metabolic upset. The symptoms appear 
most often in the morning after a twelve hour period of 
starvation. 

The diet for the mild grades of discomfort should be of 
simple, easily digested food, avoiding fats, rich sauces, salt 
or smoked meat (unless the appetite craves these, when they 
may be given in small amounts), heavy sweets, etc. Food 
should be taken often and in small amounts; and it may be 
of assistance to have the patient take a couple of crackers 
on waking or a small cup of fairly strong tea, then resting 
awhile before breakfast. 

Lynch 1 lay stress in the early and mild cases of vomiting in 
pregnancy in the habit factor as needing care in treatment. 
He advises putting the patients to bed and stopping all food 
and drink by mouth for twenty-four hours. Colonic irri- 
gation are given daily and bromids 40 to 60 gr. (4 to 5 gm.) 
given by rectum every four hours. A solution of glucose 
and soda is given by rectum 8 to 10 oz. (240 to300c.c.) given 
several times daily. The first time the patient is fed she 
should be told to control her vomiting if possible, that the 
vomiting habit is easy to form but hard to break. The first 
meal should be dry as possible. Those cases with gastric 
hyperacidity respond best to a diet of protein, limited fats 
and carbohydrates. A diet of meat with toasted bread and 
butter, and a small amount of milk or cream is especially 
recommended by Lynch. The rectal glucose solution and 
soda controls the acidosis and this symptom is usually ob- 
served when the supply of actually utilized carbohydrates 
is low, e. g., when sugars fail to be oxidized as in diabetes 
mellitus. 

A shortage of physiologically available carbohydrates, 
usually expressed in the glycogen supply of the tissues, often 
leads to the infiltration of the liver with fats, an indication 
of carbohydrate starvation in the body, as fat is not deposited 
in the liver while carbohydrates are still available. 

Duncan and Harding 2 have argued that pregnancy and a 
short period of hunger (over night) might account for the 

1 Jour. Am. Med. Assn., August 16, 1919, p. 492. 

2 Canada Med. Assn. Jour., 1918, viii, 1057. 



628 DIET IN MISCELLANEOUS CONDITIONS 



periodicity of the morning sickness due to a temporary relative 
lack of glycogen in the liver leading to a fatty infiltration. 

Applying this idea chemically they have endeavored to 
correct this assumed deficiency of carbohydrate supply in 
cases, of varying severity of nausea and vomiting, by giving 
glucose, lactose, mainly the latter and have supplemented 
this by a diet high in carbohydrates. 

They give very gratifying reports in seventy cases treated 
on this principle which is certainly worth an extended trial. 
Carson 1 says that percussion of the 5th dorsal spine causes a 
pyloric opening reflex which results in the almost immediate 
emptying of the stomach ; a useful procedure (if a fact) in 
nourishing these and other cases of severe vomiting. 

In the most severe form of vomiting of pregnancy very 
little success is experienced in nourishing the patients, all 
the methods recommended for an irritable stomach may be 
tried, colon irrigations, etc., but in the really severe cases 
emptying the uterus is the procedure that becomes neces- 
sary. Just the time at which this latter procedure is indi- 
cated is a matter of nice judgment and, of course, should 
never be decided upon singly, but only after full consulta- 
tion. Until an operation is deemed necessary everything 
to quiet the stomach that offers any reasonable hope of suc- 
cess should be tried, e. g., lavage, cocaine or menthol mixtures, 
cracked ice, sinapisms, drop doses of 95 per cent, carbolic 
acid in 1 or 2 ounces of water, followed by a trial of iced fluids 
jellies, and koumyss, or some dry solid like toast. 

Alcohol is best let alone, as a habit is more easily estab- 
lished in pregnant women and on account of its well-known 
and harmful influence on the fetus. 

Nephritis. — Close watch must be kept of the pregnant 
woman's urinary output and should albumin appear, a few 
days of an absolute milk diet will be necessary. If the al- 
bumin clears up then a return to soft diet may be made, 
principally a lactofarinaceous diet; as improvement con- 
tinues vegetables and fruit may be added, but animal pro- 
tein, except milk and eggs, is better left out of the menu for 
a considerable time after the urine becomes normal. 

Should grave symptoms of uremia develop all the methods 
ordinarily employed to combat this condition should be 
used, e. g. } milk diet, hot packs, colon irrigation, saline in- 
fusions, veratrum viride, and phlebotomy if necessary, empty- 
ing the uterus if no other measures seem to suffice. If there 
is edema with the uremic manifestations, the diet should be 
one of the salt-poor diets (see p. 453). 

1 Med. Rec, 1917, xcii, 897. 



DIET IN PREGNANCY 629 

In any event the diet as recommended for acute nephritis 
is indicated. If the outcome is favorable, without the neces- 
sity of terminating labor, the diet during the remainder of 
the pregnancy must be regulated with the utmost care, 
largely as advised in chronic nephritis. 

Mild Autointoxication. — The symptoms of this condi- 
tion are not outspoken, but consist of a little headache, a 
general feeling of lassitude, lack of ambition and possibly 
vague digestive disturbances. These are often the precur- 
sors of more serious trouble and should not be ignored ; with 
such a condition to treat, a thorough emptying of the bowel 
is necessary, followed daily by a colon irrigation of hot saline. 
The diet should be reduced in quantity and meat and meat 
soups excluded until after the symptoms clear up. Massage 
and passive movement or active exercise as walking or light 
dumbbell exercise will help in a return to normal conditions. 
Such symptoms can for the most part be obviated if the 
patients will take care not to overeat and to take regular 
and systematic exercise throughout their pregnancy. Regu- 
lar walking and abdominal exercises such as raising the legs 
while lying prone or coming up to a sitting posture from the 
prone position, help to furnish exercise, strengthen the ab- 
dominal muscles, aid in preventing constipation, and give 
much better "pushing" power at the time of greatest need. 

Contracted Pelvis or with an Oversized Fetus. — Various 
dietary regulations have been tried with a view to influen- 
cing the size of the child in order that it may pass a small 
pelvic outlet without difficulty, and of these the best known 
is Prochwnick's diet, of which the main principles are, re- 
ducing the carbohydrates and fluids during the last two or 
three months of pregnancy in the hope that the growth of 
the fetus may be kept back (retarding the ossification of the 
bones). De Lee 1 thinks the diet useless, but there are others 
who believe it accomplishes its purpose, although it should 
only be undertaken under medical supervision. It is prob- 
ably an extremely useless procedure. 

Prochwnick's Diet: 2 

Breakfast^ Small cup of coffee, ioo c.c. (3 oz.) ; bread, 

30 gm. (1 oz.); a very little butter. 
Dinner: Meat, fish or one egg. with a little sauce; vege- 
tables cooked with butter or cream; lettuce; small 
piece of cheese. 
Supper: The same as at dinner, with bread, 30 gm. 
(1 oz.); butter and a little milk. 

*De Lee: Principles and Practice of Obstetrics, p. 729. 
2 Centralbl. f. Gynecol., 1889, 33. 



630 DIET IN MISCELLANEOUS CONDITIONS 

Forbidden: Soup, pastries, sugar, beer, and potatoes. 

Water up to I pint a day or a light wine, 300 to 400 

c.c. (10 to 14 oz.) is the only fluid allowed. 

Puerperium. — During the first eighteen hours postpartum 

the mother should have liquids sufficient to quench the 

thirst, a cup of tea, water, Vichy, or broth. After this, 

coffee, milk, toast, soft cereals, milk toast, and so back to 

normal diet. After the bowels have been moved on the 

second day the amount of food can be steadily increased, 

always giving plenty of water and small midmorning and 

afternoon feedings. 

Foods Best Avoided.— Acid fruits, such as grapefruit, 
lemonade, sour oranges, strawberries, plums, tomatoes, and 
onions all may cause colic in the infant. Peas, potatoes, 
tunips, and beans so often give rise to flatulence that they 
are best left out of the diet until the mother is able to exer- 
cise and be about. 1 

The following is the postpartum diet recommended by 
Edgar : 

Diet List after Normal Confinement. 
First two days: 

Liquids: Milk, hot or cold; beef tea, weak tea; beef 
broth or chicken broth; beef juice; egg shake; clam 
broth ; simple soups and cocoa. 
Solids: Thin bread and butter; saltine or soda crackers; 
milk toast; dry or buttered toast; dropped or soft- 
boiled eggs; any breakfast cereal thoroughly cooked. 
After first two days: 

Liquids: As above with addition of coffee. 
Solids: Any breakfast cereal; scrambled, soft-boiled, or 
dropped eggs; broiled white fish; lamb chop; beef- 
steak; roast lamb; broiled, baked, or creamed chick- 
en; baked, mashed or stewed potatoes; macaroni; 
celery; lettuce; fruits; fresh vegetables, such as peas, 
asparagus, and string beans in season and in modera- 
tion; boiled or baked custard, curds and whey; wine 
jelly; simple puddings, such as rice, tapioca. 
Avoid: Nursing mothers should avoid whatever previ- 
ously disagreed with them and usually also pork, veal, 
corned beef, cabbage, turnips, cucumbers, corn, beans 
(canned and dried), vinegar, strawberries, and mel- 
ons unless thoroughly ripe. 
Sample Breakfasts: 

(1) Any breakfast cereal; soft egg; tea. (2) Orange; 
cereal and cream; scrambled egg; tea or cocoa. (3) 

Edgar: The Practice of Obstetrics, p. 673. 



SPRUE 631 

Cereal; broiled white fish; bread and butter; tea, 
coffee, or cocoa. (4) Lamb chop; stewed potatoes; 
toast; tea, coffee, or cocoa. (5) Orange; scrambled 
or dropped egg ; minced chicken ; graham bread ; coffee. 

Sample Dinners: 

(1) Broiled or roast chicken; sweet potato; baked cup 
custard. (2) Roast lamb; mashed potato; macaroni; 
wine jelly. (3) Roast beef; celery; mashed potato; 
rice pudding. (4) Simple soup; chicken; stewed po- 
tatoes; baked cup custard. (5) Raw oysters with 
any of the above. 

Sample Suppers: 

(1) Creamed chicken on toast; milk or cocoa. (2) 
Oyster stew; bread and butter; cocoa. (3) Minced 
chicken on toast; baked apple and cream; tea. (4) 
Propped eggs on toast; graham bread and butter; 
cocoa or tea. (5) Raw oysters with any of the above. 

SPRUE. 

Since the acquisition by the United States of the tropical 
islands of Porto Rico and the Manila group, and with the 
return of missionaries from the East, cases of sprue are in- 
creasingly seen and the need for a proper dietary is corre- 
spondingly necessary. Most of the cases seen are past the acute 
stage on arrival here, and the feeding problem is not so urgent 
as at the onset; relapses occur, however, in this climate, and 
it is then necessary to return to such diets as are best for the 
acute condition. Manson, 1 whose experience with tropical 
diseases makes his advice of paramount importance, insists 
on the absolute necessity of the milk diet in the early stages 
and during a relapse, and says "failure to realize this or to 
attempt half-way measures is responsible for most of the 
serious consequences of this disease." 

The milk cure as recommended by Manson is as follows: 
For the first twenty-four hours 60 ounces of milk are allowed ; 
the milk should not be drunk but sipped with a spoon in 
very small amounts. After the first day the quantity of 
milk should be increased at the rate of ]/ 2 pint a day or every 
other day until 100 ounces are taken in twenty-four hours. 
This amount should be continued for ten days, and then if 
everything is satisfactory the amount may be gradually 
increase up to 6 or 7 pints. The length of time this should 
be kept up is as Manson says "for six weeks, dating from the 
time the stools become solid and the mouth free from irrita- 

1 Tropical Diseases, New York, 1908. 



632 DIET IN MISCELLANEOUS CONDITIONS 

tion." No other food or drink whatever should be per- 
mitted. After this a raw egg, artificially malted cereals, 
well-boiled arrow-root, stale bread, or zweiback and butter. 
Later chicken broth and a little fruit. Still later fish, and 
chicken. Cases that cannot take plain milk may be given 
it peptonized or as koumyss, etc. The fruit treatment in 
connection with milk has also found much favor in certain 
quarters and the taking of bananas and apples has been 
found useful. Strawberries seem to be especially helpful, 
and Manson begins by giving one or two berries with each 
milk feeding, increasing the amount until 2 or 3 pounds 
are taken daily. Preserved fruits, especially peaches and 
pears, are allowed in case strawberries are not to be had. 
In the light of our present knowledge the usefulness of the 
strawberries may well be due to its contained water soluble 
B (vitamines). 

Occasionally a patient is found who cannot take milk in 
any form or in whom the milk treatment fails; these cases 
often do well on meat juice, and after a day or two, scraped 
meat, later the thoroughly toasted bread or biscuits, and a 
gradual advance as already described. During the early 
stages of treatment a certain amount of nourishment can be 
introduced by means of nutritive enemata. (See Section on 
Rectal Feeding.) As the patients get on a more mixed diet 
it will often be seen that the stools are distinctly fatty and an 
examination for the normal ferments shows markedly defi- 
cient trypsin and amylase with or without a high total free 
fat above the normal (25 per cent, in feces). The stools may 
seem digested, but the assimilation is poor and the body 
weight remains fixed low or decreasing. 

These evidences of impaired pancreatic digestion are quite 
regularly present in practically all the cases at some stage of 
the disease, and much benefit is derived by giving commer- 
cially prepared ferments, as diastase and dried pancreatic 
extracts (in salol or keratin-coated capsules). When the gas- 
tric digestion is impaired, as shown by the results of a test- 
meal analysis, dilute hydrochloric acid and pepsin are help- 
ful. 

As little or nothing is known of the etiology of this disease 
the dietary routine is, of course, purely an empirical one and 
has been built up entirely on clinical experience. The de- 
termination of gastric or pancreatic loss of function to a 
greater or less degree is a matter of routine examination, 
and taking advantage of the findings often results in the 
increased absorption of food, with consequent gain in weight. 



DENTAL CARIES 633 

DENTAL CARIES. 

It is common knowledge that dental caries is on the in- 
crease, and although it is also true that more attention is 
given to the teeth than formerly, and some of the bad effects 
of the caries are minimized, the original statement holds true. 
Durand 1 calls attention anew to the influence of diet on the de- 
velopment and health of the teeth, quoting various authorities, 
and comparing the dental caries of the present-day children 
with evidences of the same trouble in the examination of 
prehistoric skulls. An examination of 10,500 English and 
Scotch school children, showed dental caries in 86 per cent. ;* 
among 19,725 children in northern Germany, 95 per cent.; 
and in the United States the record was little better. Among 
ancient British and Anglo-Saxon skulls decay was found in 
only 15 per cent.; of Anglo-Saxon, 2.9 per cent.; British of 
stone age, 21.8 per cent.; bronze age, 32 per cent. 3 

A good many different factors have been blamed for this 
condition, prominent among which are the softness of the 
foods given, requiring little chewing, the extreme tempera- 
tures at which foods are fed, varying from ice-cream to hot 
coffee and the tremendous per capita increase in the con- 
sumption of sugar throughout the civilized world. Bearing 
on this last point Seagrave, for the Seattle Department of 
Public Health, examined the teeth of 2000 children from two 
to seven years of age who had been fed for the first six months 
of life on either breast milk, cow's milk mixtures or sweetened 
condensed milk, with the following results: 

Number Number Percentage 

.Food. examined showing caries of caries 

Breast milk . . . . . . 829 366 42 . 6 

Cow's milk mixture . . . 232 102 42.9 

Sweetened condensed milk . 61 41 72.1 

Durand's figures bearing on the same conditions are as 
follows : 

Breast milk 418 fi8 28.2 

Cow's milk mixtures . . . 102 30 2 9-4 
Sweetened condensed milk .32 17 53.1 
Sweetened condensed milk (pri- 
vate cases) 104 77 74 .0 

Durand says "the significance of these statistics is that a 
poorly balanced diet, high in carbohydrate (particularly 
sugar— Ed.) and low in fat, protein, and mineral constituents 
fed during the period in which the teeth are developing and 

1 Jour. Am. Med. Assn., 1916, lxvii, 8, p. 564. 

2 Rose, in British Dental Association Report, quoted by Smale. 

3 Mummery: Tr. Odont. Soc, ii, 215. 



634 DIET IN MISCELLANEOUS CONDITIONS 

calcifying in the jaws, seems to have rendered them doubly 
susceptible to decay after they erupted." 

From this it is evident that the proper feeding for children 
does not include condensed milk, except for very short periods 
of time to combat, for instance an intestinal indigestion, 
nor sweets in generous amount at any time. 

The diet should be breast milk or properly modified cow's 
milk, giving vegetables, fruits, and meat as early as possible, 
these latter may often be given as early as the sixth month. 
It is also advisable to give a child foods that require chewing, 
as "strips of tough meat, bacon rind, bones, tough crusts, hard 
bread, and later apple, celery, lettuce, etc." Durand em- 
phasizes the fact that the last article of food eaten should not 
be some sweet carbohydrate which will leave a decaying 
residue, but an acid fruit which produces a highly alkaline 
saliva with a high percentage cf ptyalin. In a practical 
test by Wallace 1 14 children were fed on these principles 
and at the ages from five to seven years there was not the 
slightest evidence of caries. 

DIET IN CANCER. 

In the absence of definite knowledge of the etiology of 
cancer any method of dietetic treatment must necessarily 
be empirical and although many methods of diet have been 
tried to combat the disease, it must be said that in human 
cancer the progress and results have been exceedingly meagre 
and hardly encouraging. 

In 1880 Beneke 2 found cancer cells rich in cholesterine 
and observation had shown that cancer was more frequent 
in carnivora than in herbivora and more frequent among 
people who were great meat eaters. On this basis Beneke's 
diet was designed with little nitrogenous food. Kessler 3 
designed a diet low in sulphur on the basis of this knowledge 
that the sulphur metabolism is disturbed in cancer, giving 
only sulphur free foods or with a minimum content. 
For nitrogenous foods he allows: 

Fish: Halibut, salmon, white fish, cod, mackeral her- 
ring, shad, black fish, Spanish mackeral and porgy. 
No meat of ox or blood (rich in sulphur). 
Buttermilk is also bad and egg yolk, not white. 

Vegetables allowed are: truffles, rhubarb, beets, chicory, 
pumpkin, lettuce, beans, peas, romain salad, chestnuts. 
Cereals: Wheat, oatmeal, rice, corn bread, barley, buck- 
wheat, poppy seed, graham bread. 

1 Dental Record, London, 1912 p 56. 

2 Deutsch Arch, fur Klin Med., xv, 1880. 

3 New York Med. Jour., Nov. 30, 1917. 



DIET IN CANCER 635 

Fruits; Almonds, olives, plums, oranges, huckleberries, 
strawberries. 
Casein and butter, as they are almost sulphur free. 
.Sample menu of Kessler's diet: 

Breakfast: Tea or coffee with sugar and cream. 

(No milk on account of lactalbumin which is high in 

sulphur). 
Fresh or cooked fruit. 
One of the cereals allowed. 
Dinner: Soup of fruit, cereals, or vegetables (not meat). 
Beans, peas, lentils. 
Meat, two ounces at most. 

Potato dumplings, carrots, beets or other edible roots. 
Boiled or preserved fruits, rice and salad. 
Casein is added to the food to bring up the protein to nor- 
mal or is given as medicine I to 3 drams (4 to 12 gm.) every 
three hours. 

Supper: Fruit with rice, potato and butter, salads. 
Centanni 1 says the idea of dietetic treatment of malignant 
disease is not new, but hitherto the experiments have been 
made with a diet which starved all the cells. The conse- 
quence was that the normal cells were too weak to contend 
with the cancer cells and the malignant disease was merely 
whipped up by the modified diet. Centanni, on the other 
hand, sought to modify the diet in such a way that it amply 
sufficed for the nourishment of all the cells, cancer cells in- 
cluded, but the substances in the diet which promote growth 
were all carefully excluded, and others added which tend to 
inhibit growth. Modern research has demonstrated a number 
of food substances which promote growth — he calls them" blast- 
ins' ' and he emphasizes that cancer cells do not differ essenti- 
ally from normal cells except in their "tumultuous multipli- 
cation." By depriving them of those elements in the food 
the fundamental office of which is to sustain the multipli- 
cative function, auxetics, Wuchsstoffe or blastins, and for 
which the cancer cells display exceptional avidity, the tumor 
cells languish and die. Among the facts which testify to 
the correctness of this assumption are Haaland's experiences 
— confirmed by others — to the effect that gestation prevents 
successful grafting of tumors and checks the growth of those 
already implanted. The physiologic growth of the fetus 
victoriously combats the pathologic growth of the cancer. 
In Centanni's research he experimented, with ninety-three 
series of from four to ten mice each. On ordinary food, 100 
per cent, of the tumor grafts "took" and some grew to be 

1 Reforma Med., 19 18, xxxiv, No. 32. 



636 DIET IN MISCELLANEOUS CONDITIONS 

larger than the body of the mouse to start with. Given the 
restricted diet ten days beforehand, none of the grafts " took " 
or only feebly grew. On this diet, tumors already estab- 
lished, up to 2 or 2.5 cm. in diameter, became arrested and 
were finally reabsorbed without leaving a trace. Large 
tumors softened and decayed to a friable mass. The most 
striking results were obtained when the main mass of the 
tumor was resected and the remainder became reabsorbed 
as the animals were kept on the blastin-free diet. The 
growth promoting substances are certain vitamines, certain 
internal secretions, and certain chemical substances. In his 
experimental diet he took particular pains to exclude the anti- 
scurvy vitamine and nuclein and phosphorus compounds, 
and denatured the food by heating to 125 or 130 C. The 
outlook for application of the principle to man seems hopeful 
as human beings are particularly sensitive to lack of vita- 
mines, while the size of the cancer in proportion to the whole 
body is immeasurably smaller than in the experiments re- 
lated. On the other hand, the results will take much longer 
to become manifest. The method is harmless, as any dis- 
turbances from a dietetic deficiency would be recognized 
early and could be promptly remedied. Experienced medi- 
cal supervision would be indispensable. 

DIET RECOMMENDED FOR SPEAKERS AND SINGERS 

These people, as a rule, should eat a mixed diet, obeying 
the rules of moderation and hygiene as should others. It is 
best for the voice not to take food for a few hours before it is 
to be used, so that people who sing or expect to make a speech 
in the evening have the habit of eating a light meal at about 
5 p.m., and nothing then until after the performance, when 
they again take something to eat. All sorts of dietary fads 
have arisen among professional singers and actors of taking 
some one special form of food before using the voice and find 
no harm, but there is little evidence that these special foods 
have a specific effect or lack of it. Their chief usefulness lies 
in the fact that it is usually confined to one article of diet in 
small amount so that no particular effect follows its use. 

When the voice is husky, sucking a lemon with a small 
lump of sugar imbedded in it helps some people, others find 
dram doses of whiskey and glycerin or whiskey, glycerin and 
lemon juice of value. The value, however, of many of these 
things is more fancied than real. 



DIET FOR ATHLETES 637 

DIET ADAPTED TO THE USE OF BRAIN WORKERS. 

The requirements of food for brain workers do not differ 
materially from those of other people leading a sedentary 
life, for, contrary to the general opinion, brain work does not 
require as much food as muscular work of a corresponding 
degree of intensity. It is necessary for these people to take 
more food than those who are absolutely quiet without any 
occupation, but the difference is slight. On the other hand, 
while the quantity may be only that of the person at ordinary 
activity there is the greatest necessity for care in the selec- 
tion of the kind of food to be eaten. It is necessary to avoid 
indigestible foods of all kinds, as these people are prone to 
indigestion, and on account of their lack of exercise have not 
the vitality for digestion that their more active brothers 
have. The food should therefore be simple with the avoid- 
ance of heavy meats, such as pork, veal, corned or salt meat 
or fish, pies, pastry, heavy sweets as preserves, rich sauces 
and salads, devilled crabs, etc. 

Fish was formerly thought to be of special value in the diet 
of brain workers on account of its large percentage of phos- 
phorus, the brain also requiring a larger amount of phos- 
phorus than the rest of the body, as shown by its chemical 
analysis. The theory has been completely disproved, and 
fish is only so much protein so far as feeding goes. 

Brain workers should take alcohol only in the greatest 
moderation, or better none at all, as without exercise the 
injurious effects of alcohol are greatly exaggerated. 

DIET FOR ATHLETES. 

Much has been written on the subject of diet in connection 
with feats of muscular strength, more particularly for ath- 
letes, and one may get a variety of opinions for the asking. 
Much of the subject is founded on the personal experience 
and observations of trainers, and although a good deal of 
scientific work has been done in America, particularly, and 
forms a basis for many of the rules, the greater part is based 
on clinical observation. It has been a rule that those engaged 
in severe muscular effort should eat a larger proportion of 
protein food than should those who live an ordinary life or 
who take a moderate amount of exercise. 

The experiments of Chittenden have shown that a man 
may thrive on about one-third the ordinary allowance of 
protein and yet be capable of a large, though perhaps not 
excessive, amount of muscular work. While this is an es- 
tablished fact it is a question that needs longer experience 



638 DIET IN MISCELLANEOUS CONDITIONS 

to prove that the same rule holds true for those engaged in 
severe work, and it is probable that rather more than this 
minimum protein allowance is the optimum for athletes, 
although protein destruction does not go on at a much higher 
rate in athletes. The mere fact that excessive effort has 
always been accompanied by a very large protein intake does 
not necessarily mean that this is the best regimen, for above all, 
the excretory organs should not be given an extra amount of 
unnecessary work by the ingestion of an excessive diet, 
particularly of the proteins. 

Carbohydrates and fats spare the protein combustion and 
should constitute a considerable excess proportion of the 
athlete's diet, and the fact that the effort is to be excessive 
and of short duration calls for a different proportion of the 
food elements compared with that needed for sustained muscu- 
lar work. Thus, in short, running dashes, feats of strength 
which are quickly over, there is need of a greater proportion 
of carbohydrates (sugars) for although the specific dynamic 
action of protein is greater the heat derived from this is not 
available for work. 1 When a sustained muscular effort is 
to be made fats are of great importance as well. An interest- 
ing illustration of the latter is seen in the diet of the Western 
cowboys, who find that if they have a long piece of hard 
work ahead of them, with little chance to eat a proper meal 
until night, they can accomplish this most easily if their meal 
before starting contains a large percentage of fat. This is 
because the combustion of fat is much slower than that of 
either protein or carbohydrate, and its availability as food 
reaches its maximum a much longer time after its ingestion. 

Three meals a day are better for all athletes than repeated 
small meals, and the diet should be a generally mixed one. 

The association of gradually increasing work and increas- 
ing diet is an important one, and the food required by a man 
in training, to a certain extent, should keep pace with his 
muscular development; in other words, training consists in 
a gradual increase of effort and diet should be increased 
accordingly, i. e., the largest diet should not be allowed in the 
early days of training. The end of training should also be 
marked by a decreased diet, not always a simple matter, for 
it is easy to acquire the habit of large eating, and its con- 
tinuance after the necessity for it is past. This dispropor- 
tion is said to be the cause of much of " farmer's indigestion, " 
a continuance of a large dietary during the winter when there 
is comparatively little muscular effort required in the run- 
ning of the farm. 

1 Paul E. Howe. 



DIET FOR ATHLETES 639 

When it comes to actual figures to express the needs of the 
body for severe muscular work, we can, of course, only deal 
with averages, keeping in mind the underlying principles of 
diet already referred to. 

The following figures are presented so that there may be 
compared some diets actually in use with standards expres- 
sive of the body's requirement during severe muscular exer- 
cise. 

Rowing Protein Fat Carbohydrate Calories 

Average of six 

crews . . 155 gm. (5 oz.) 177 gm. (6 oz.) 440 gm. (14^ oz.) 4085 

Football aver- 
age of two 
teams . . 225 gm. (7^ oz.) 354 gm. (12 oz.) 633 gm. (21 oz.) 6812 

Standard (Voit) 
hard muscu- 
lar work . 145 gm. (5 oz.) 100 gm. (3^ oz.) 450 gm. (15 oz.) 3370 

Hard muscu- 
lar work 
(Playfair) 1 185 gm. (6 oz.) 71 gm. (2^ oz.) 568 gm. (19 oz.) 3750 

From this comparison it will be seen that the diet actually 
used by the crews differs little from the Yoit standard, 
whereas the football teams consumed a very much greater 
proportion of all three food elements. This is comparable 
to the difference in the length of time consumed in the con- 
tests — a rowing race of four miles lasting usually from thir- 
teen to fifteen minutes, a football game, an hour, with one 
short intermission— the caloric needs also of the latter being 
apparently about 50 per cent, greater. These dietaries are 
of course founded on experience perhaps rather than on ac- 
tual food requirements. 

Sugar. — Much has been written on the usefulness of con- 
siderable amounts of sugar for athletes but definite conclu- 
sions based on accurate experimentation are lacking. There 
is no doubt but that sugar forms a readily usable form of 
carbohydrate, with high caloric value, and may, in modera- 
tion, form part of an athlete's diet; but that one should take 
excessive amounts of it for this purpose is not in all proba- 
bility a wise thing, as it may easily result in a disturbed 
digestion, both gastric and intestinal, accompanied by fermen- 
tation. 

The diet for athletes, as already stated, should be a mixed 
one, consisting of meats, fish, eggs, milk, cereals, stale bread, 
roll, or toast, occasionally baked potato, macaroni, rice or 
other farinaceous articles, a moderate allowance of sugar, 
fats of all sorts, especially butter, cream, and fat meat. 
Green vegetables, ripe fruits, fresh or stewed. Water taken 

1 Bulletin 21, U. S. Dept. Agriculture. 



640 DIET IN MISCELLANEOUS CONDITIONS 

largely between meals or an hour before and after exercise 
(but never iced). Some trainers allow weak tea and coffee, 
but it is probably that those in training are better off without 
either. The same rule applying to all alcoholic beverages, 
although an occasional glass of mild beer may have a tonic 
effect when the appetite is uncertain. 

Foods to Avoid. — Soups, except an occasional puree. 
Tough, indigestible meats, as veal, pork, salted meats or 
fish, except occasionally a bit of bacon. Gravies, rich en- 
trees, spiced food, hot breads and cakes or rich cake (cookies 
and a little dry, simple cake are allowable). Candy and 
pies. Wine, beer, ale, spirits, tea and coffee. 

Dietary Rules for Athletes. 

1. Eat slowly and masticate all food thoroughly. 

2. Do not exercise violently for at least an hour to an hour 
and a half after meals, better two or three hours. 

3. Do not eat immediately after exercise, allow at least 
thirty to forty-five minutes for actual rest. 

4. Do not wash food down with any fluids, a moderate 
amount of fluid with meals is permissible, but should be 
drunk between mouthfuls or at the end of the meal. 

5. Water in any desired amount may be taken during the 
day, the bulk of it is best taken between meals or at least a 
half-hour before eating. 

6. Do not eat an excess of any kind of food with the idea 
that the more food one takes the stronger one will be, the 
opposite is much nearer the truth. 

7. Remember that milk is a food and should never be used 
merely to quench one's thirst. 

8. Avoid tea and coffee and alcoholic beverages. 

THE FEEDING OF UNCONSCIOUS PATIENTS. 

In many if not most unconscious patients the swallowing 
reflex is preserved, so that food is automatically sent down 
the esophagus as soon as it reaches the posterior pharyngeal 
wall. In such cases it is possible to feed a certain amount by 
the spoon or slipping a small catheter into the side of the 
cheek on the dependent side and pouring liquid food into 
the funnel very slowly. If only a quantity equal to a nor- 
mal swallow is given at a time, this does very well; faster 
feeding or the giving of greater amounts will cause laryngeal 
irritation and choking. 

If this method is not easily accomplished the simplest way 
is to feed by gavage through the nose or mouth, which ever 
proves easier. This is done as follows : 



FOOD POISONING 641 

A small-sized, smooth-rubber catheter is lubricated with 
vaseline or some lubricating jelly and passed through the 
nose down the throat beyond the laryngeal opening or 
through the mouth to the same point. A glass funnel is 
then attached to the distal end, and the liquid food, warmed, 
is poured slowly down. When the feeding is finished, in 
removing the tube close the lumen by bending or squeezing 
it between the thumb and forefinger. This will prevent 
the few remaining drops from getting into the larynx. 

The food best adapted to this use are some of the milk, 
cream, and lactose mixtures recommended for typhoid fever 
patients (p. 575), to which raw eggs, beaten up, may be added, 
or thin cereal or the food formula given under suralimenta- 
tion, may be tried. The intervals of feed'ng should 
be as long as possible, preferably not oftener than three 
times in the twenty-four hours The caloric needs of the 
individual must be considered in arranging for the exact 
quantity to be used in the twenty-four hours. 

FOOD POISONING. 

The importance of poisoning by food is impressed by prac- 
tical experience upon everyone at some time in their lives, 
and he is fortunate who is not rendered helpless or worse by 
such an experience. At one time or another almost every 
article of food belonging to anyone of the classes of food 
constituents has been blamed for causing symptoms of poison- 
ing, many of them, legitimately, others in error. Individual 
susceptibility plays a great part in the precipitation of symp- 
toms, and in a given instance, where a number of persons are 
poisoned at the same time after eating approximately the 
same amount of the tainted food, some are made much more 
ill than others, while at the same time some are entirely 
unaffected. This is particularly well seen in the hypersus- 
ceptibility of certain persons to a particular protein snowing 
an anaphylactic reaction when another is untouched by the 
same condition. 

Food Poisons May be Divided into: 

1. Endogenous (to the food). 

2. Exogenous. 

1. In endogenous poisonous foods the poison is an inherent 
quality of the food, as muscarine in mushrooms. The blood of 
some eels is poisonous from preformed physiological products. 
Some mollusks and fish are believed to be poisonous at cer- 
tain phases of their sexual life. Certain fish are highly 
poisonous even when fresh, probably from leucomains and 
41 



642 DIET IN MISCELLANEOUS CONDITIONS 

basic alkaloidal substances elaborated by the cell meta- 
bolism. 1 

2. Exogenous poisonous foods are the more common and 
may be divided into (a) poisonous compounds, such as the 
metals, arsenic, tin, antimony, lead, zinc, and copper; (b) 
animal parasites such as trichinae, etc.; (c) the most fre- 
quent form is due to bacteria and fungi. Food infection is 
thus the most frequent form of food poisoning and can affect 
every sort of food imaginable. 

Milk as one of the chief articles of diet is particularly sub- 
ject to contamination; it is an ideal culture medium for cer- 
tain bacteria, giving rise to all sorts of gastro-intestinal 
inflammatory conditions in infants, besides acting as a car- 
rier in typhoid, streptococcus sore throat, scarlet fever, and 
cholera. Milk poison as such or galactotoxismus is analo- 
gous to meat or fish intoxication. Tryotoxicon also pro- 
duced in milk, cheese, and ice-cream (discovered by Vaughan 
in 1885), is probably not the product of one organism but 
of several. 

Meat Poisoning. — Three kinds: 2 

1. Due to eating meat from diseased animals. This is 
usually associated with the Bacillus enteritides or paratyphi. 

2. Due to eating putrefied meat, usually associated with 
Bacillus proteus and Bacillus coli. 

3. Due to " sausage poison" produced by the anaerobic 
Bacillus botulinus. 

The first kind is often from freshly killed meat, the other 
two when the meat has been kept awhile. The first two 
kinds of poisoning are of the gastro-enteric type and the 
third gives symptoms referable to the central nervous sys- 
tem. 

Fish Poisoning. — 1. Poisoning in which the poison exists 
in the living animal. 

2. Those in which the poison develops subsequently. 

Certain fish or parts, e. g., roe or ovarian tissue, are some- 
times poisonous, giving rise to choleraic symptoms, paralyses, 
convulsions, and often death. This poison is present in the 
"fugu" roe, also the roe of barbs (German fish) when eaten 
in May is poisonous, and, according to Kobert, the liver and 
bile of a number of fish are poisonous. Some mussels and 
snails are poisonous. Oysters convey typhoid when fattened 
in polluted beds. Shell fish usually give rise to poisoning by 
either anaphylaxis or direct bacterial poisoning, which may 
show itself in three forms: 

1 Ref. Handbook Med. Sc, 1914, 3d edition, iv, 420. 
3 Bolderon: Food Poisoning, p. 15. 



FOOD POISONING 643 

i . Gastro-enteric type with nausea, vomiting and diarrhea. 

2. Exanthemic type showing skin eruptions, erythema- 
tous, vesicular or urticarial. 

3. A type of poisoning much like botulism and affecting 
the central nervous system. 1 

Vegetable Poisoning. — Potato poisoning was at first 
thought to be due to solanin, but the quantity of solanin even 
in two pounds of potatoes is too small to cause symptoms, 
and it is more probable that potato poisoning is due to bac- 
terial decomposition of potatoes by proteus bacilli, as ob- 
served by Dieudonne. 2 The poisoning from potatoes is more 
apt to occur when the potatoes are cooked one day and kept 
in large pots or containers until the next day, before being 
eaten, and in warm weather the decomposition can take 
place very rapidly. Most of the outbreaks of potato pois- 
oning have taken place in July and August, and usually 
when new potaoes are used. 

Poisoning by Canned Goods. — Meats, fish, and vegetables 
which, if not absolutely sterilized when canned, undergo 
putrefaction with the evolution of gas, which can be known 
by inspecting the can, for under such circumstances the top 
of the can is convex or bulging, and when it is opened a foul 
odor and gas escape. 

Canned salmon has a particularly bad reputation among 
fish. Numerous outbreaks have been reported after eating 
canned vegetables. String beans have been often at fault; 
but no matter which vegetable is to blame there is no ques- 
tion but that all these outbreaks of poisoning can be traced 
to a bacterial origin of one or another kind. 

In the vegetable poisoning we have moulds as a factor, 
which is not true of meat or other animal products, such as 
fish, roe, eggs, and milk, which are strictly bacterial in origin; 
thus, for example, we find ergot of rye the cause of ergotism. 

It would be possible to go on indefinitely multiplying 
examples of poisoning by almost every form of food which 
had become infected, but enough has been said to point to 
the importance of the subject to persons in health, and to 
those already suffering from disease an additional burden of 
intoxication, from such a cause, may easily prove fatal. 

What, then, has this subject to do with dietetics? Every- 
thing from the point of view of prophylaxis, very little when 
the mischief has already been done. There are, however, 
certain dietetic and culinary precautions which should be 
observed, most of which are so self-evident as hardly to need 
mention. 

1 Ibid., p. 915. 2 Deutsch. Militar Ztschr., 1904. 



644 DIET IN MISCELLANEOUS CONDITIONS 

Dietary Precautions. — I. Only fresh food should be bought 
from a reliable dealer, unless the buyer is able to decide for 
himself just what is fresh. 

2. Meat that tastes "queer," oysters that are spoiled, and 
meat that is bitter, strong, or rancid should be ejected from 
the mouth, no matter in whose society. It can be artisti- 
cally done. 

3. Cooking thoroughly, broiling, roasting, or boiling kills 
most of the bacteria, but is usually ineffectual in removing 
the products of decomposition or in making them ineffective. 
Ordinary boiling does not kill all kinds of bacteria; most are 
readily killed but some resist prolonged boiling. Bacillus 
botulinus is easily decomposed by heat, while Bacillus para- 
typhi produces a poison which cannot be eliminated even by 
boiling a long time. 1 

4. Not less than a 15 per cent, solution of salt should be 
used as brine for salting, and smoking food must be done 
very thoroughly, or in either case the bacteria will not be 
destroyed. 

5. Fish if frozen fresh, will keep almost indefinitely without 
loss of essential good qualities, palatability, or change in 
sanitary characteristics. 2 But if the fish are frozen after 
being infected when they are thawed for cooking the poison- 
ous effects will be seen as readily as if they had not been 
frozen. 

6. Food should be eaten as soon as convenient after cook- 
ing, and should not be kept for long intervals. If necessary 
to keep food over, particularly in hot weather, it should be 
cooked again just before eating. 

7. Canned goods should never be used if the can is seen to 
have a convex top, as this is always due to imperfect steriliza- 
tion, with resulting fermentation and putrefaction, the bulg- 
ing being caused by the gas under pressure. These cans are 
called "swells" or "blow" cans. 

8. All canned food should be thoroughly cooked through 
before serving, to kill any possible organisms, and if the en- 
tire canful is not used at one meal it should be kept in stone 
or enamel ware on ice and not in the can. 

9. Meat and potatoes after being cooked together should 
not be kept over night as a ptomain (?) is developed that is 
exceedingly apt to cause a severe diarrhoea particularly if 
the food is not kept on ice. 

If by chance it becomes necessary to prescribe a diet for a 
patient who is suffering from food-poisoning one should fol- 

1 Munchen. med. Wchnschr., 1902, xlix, 1817. 

2 Biochem. Bull. Col. University, New York, October, 1913, p. 54. 



SPECIAL DIETARY CURES 645 

low the rules laid down for the diet of the concomitant condi- 
tion which it causes, e. g., diet for acute gastritis, gastro- 
enteritis, or enterocolitis, according to which part of the in- 
testinal canal is affected. It is needless to say that if any 
food is remaining in the stomach or intestine, patients must 
have gastric lavage, quick and effectual catharsis, and high 
colonic irrigations. 

SPECIAL DIETARY CURES. 

As long as food is necessary to man, just so long will there 
be dietary fads, and greater or less stress will be put upon the 
omission or taking of one or another class of food-stuff, 
largely according to the effect upon the individual originat- 
ing the special form of dietary. While this is so, there de- 
velops, as a result of these various diets, valuable suggestions 
which may be applied with equal benefit to other forms of 
more normal dietaries. Thus, many of Fletcher's ideas are 
excellent and useful for anyone to apply — so, too, the em- 
phasis placed upon the taking of more vegetable foods, 
fruits, nuts, etc., is valuable — but few people are willing to 
abide by a hard-and-fast method of eating, and rightly, as 
the individual equation is always important and must be 
considered. There are, of course, many more forms of die- 
tary cure than the few mentioned in the text, but it hardly 
seems worth while going into the subject more extensively. 

The Vegetarian Diet. — Vegetarianism, as a propaganda, 
has been so befogged by prejudice, ignorance, and inaccuracy 
that it has never received support from any considerable pro- 
portion of the inhabitants of the temperate zone, and lack of 
opportunity has, of course, shut out from its use those who 
live in excessively cold climates. Many of the inhabitants 
of the tropics, on the other hand, voluntarily have assumed a 
modification of this diet, largely as a matter of expediency, 
and because they found that a flesh diet was not one that gave 
them the best physical results. Thompson calls attention 
to historical and anthropological facts, such as the structure 
of the teeth in prehistoric skulls, the character and length of 
the digestive canal, organs and secretions to prove that man 
has always been omnivorous, and that he is intended to be, 
is evidenced by the presence of free hydrochloric acid and 
pepsin in the gastric secretion, which are of no particular use 
in the digestion of vegetable protein. Of the diets of ab- 
original people, some were largely vegetarians, some largely 
meat-eaters, depending on the seasons and the opportunities 
for obtaining principally one or the other form of food, but 



646 DIET IN MISCELLANEOUS CONDITIONS 

all have been mixed feeders when possible. Some famous 
men have been vegetarians, but one suspects that they would 
have been famous anyhow regardless of their diet, and Hall 1 
says that history fails to show that a people on a vegetable 
diet ever rose very high in the scale of civilization, most of 
the world's work being done by people in the temperate 
zone, where a mixed diet is the rule. Those who advocate 
a vegetarian diet do so on these grounds: 

1. Physiological, in that vegetarianism tends to prolong 
life, make it healthier, and produces a better temperament. 

2. Economical, in that it is less costly to the individual 
and the state. 

3. Moral, in that humanity forbids the slaughter of ani- 
mals for food. 2 

In support of the physiological grounds for a vegetable 
diet, Newman 3 holds that: 

1. The rich who eat meat largely are the ones subject to 
gout, arteriosclerosis, etc. 

2. That vegetarians recover more quickly from wounds. 

3. That they are less liable to epidemic diseases. 

4. That cases of extreme longevity are usually found 
among those that live exclusively on a vegetarian diet. 

These claims, of course, are categorically contradicted by 
the advocates. of a mixed diet. 

While it is true that nitrogenous equilibrium can be main- 
tained when the protein of peas, beans, and some leaf proteins 
is substituted for that of meat and milk, it is necessarily done 
at the expense of a dietary excessive in amount, for although 
the protein of vegetable origin is assimilable it is not nearly 
so much so as that of animal origin. McCollum has also 
shown by animal experiments that the protein derived from 
seeds of plants alone is incapable of supporting life but that 
the protein of the leaves of plants must be added in 
order to maintain the equilibrium. Vegetable protein is so 
intimately associated with the cellulose and starch, it is 
metabolized with difficulty, as much as 17 per cent, being 
lost. 4 The extreme of this is perhaps best seen in mushrooms 
where the percentage of protein is very high, so accounting 
for its popularity as a food, whereas, chemical analysis of 
the stools shows that practically none of its contained pro- 
tein is assimilated. 

The greater bulk of this diet has certain disadvantages: 

1. In that the stomach and bowels are somewhat dis- 
tended, as seen in cattle with their large bellies, also noted 

1 Nutrition and Dietetics, p. 46. 

2 Rutgers: Ztschr. of Biol., 1888, xxiv, 351. 3 Essays on Diet, p. 87. 
4 Thompson: Dietetics, p. 33. 



SPECIAL DIETARY CURES 647 

among certain cases of the Irish, where a similar condition 
known as " potato belly" is well-known. This tends to the 
enfeeblement of the digestive organs and diarrhea. The 
average stool of the meat-eater is 120 gm.; that of a vege- 
tarian 333 gm. 1 

2. So much muscular effort is necessary to digest the food 
that it necessitates a large amount of blood and nervous 
energy. 

3. The great amount of water is a disadvantage and 
causes softness from retained water, and probably accounts 
for the low resistance to disease often seen in vegetarians. 

In comparing the protein of meat and vegetables we find. 2 

100 parts of lean beef contain 89 parts of protein. 

100 parts of fat beef contain 51 parts of protein. 

100 parts of pea flour contain 27 parts of protein. 

100 parts of wheat contain 16 parts of protein. 

100 parts of rice contain 7 parts of protein. 
This illustrates that vegetable protein to be sufficient must 
be eaten in large amount. When it comes to a consideration 
of the vitality of vegetarians we meet with opposing views, 
those recommending mixed feeding feeling sure that vitality 
is much higher than under a vegetarian regimen. The 
Japanese, on the other hand, although largely vegetarians, 
have great vitality but small stature; but, as a matter of 
fact, few of them are exclusively vegetarians, for, as a people, 
they eat much fish and consume milk and eggs. 
There are three classes of so-called vegetarians. 

1. Those who eat nothing but cereals and vegetables. 

2. Those who together with vegetable and farinaceous 
foods, also consume animal protein in the form of eggs and 
milk. 

3. Fruitarians living exclusively on fruits, nuts and cereals. 
There are comparatively few strict vegetarians of the first 
and third classes and when one hears of people being vege- 
tarians, it will almost always be found that at least milk and 
eggs are included in their diet. 

Metabolism of Vegetarians. — Recently an effort has been 
made to advocate a vegetarian regimen on a strictly scientific 
basis 3 and the " measure of the basal gaseous metabolism, 
which may be considered as the carbon-dioxide production 
and oxygen consumption during complete muscular repose, 
and at least twelve hours after the last meal, gives an admir- 

1 Voit: Ztschr. f. Biol., 1889, xxv, 232. 

2 Hutchinson: Food and Dietetics, 3d edition, p. 173. 

3 Buttaer: A Fleshless Diet, F. A. Stokes & Co., 1910. 



648 DIET IN MISCELLANEOUS CONDITIONS 

able index of the metabolic activity." 1 Benedict and Roth 2 
have followed this out on persons who have been vegetarians 
for years, and found that heat production per twenty-four 
hours as computed from the gaseous exchange showed that 
the vegetarians produced 25.5 calories per kilo and the non- 
vegetarians of like height and weight, 26.4 calories; also, 
there was too little difference between the respiratory quo- 
tients to be taken as evidence of a larger glycogen storage 
in vegetarians as compared with non-vegetarians. 

The evidence thus shows there is no advantage in a strictly 
vegetarian diet, and although it is possible to live and thrive 
fairly well on such a diet, its disadvantages are too great to 
make it probable that, except for short periods and possibly 
in the tropics, it will ever become a universal diet. The 
anthropological history of the world shows that in the earliest 
times men often lived largely on meat; when civilization 
brought class distinctions the poorer classes ate less meat, 
the richer classes more meat, increasingly so. Of late there 
has been a distinct reaction in the meat-eating of the wealth- 
ier classes, and one sees less meat and more vegetable food 
consumed than formerly. Civilized people become more 
sedentary in their habits as they progress upward in the 
scale of civilization, and find they need less of the stimula- 
ting qualities of animal protein; and, because, also, on ac- 
count of their sedentary habits, people find that the ingestion 
of considerable quantities of animal protein, with the conse- 
quent increase in intestinal putrefaction, gives rise to symp- 
toms of toxemia, which have assumed a very definite place 
in the pathology of disease. 

Vegetarian Diets. — When it is necessary or advisable to 
make use of the vegetarian regimen plus the usual addition 
of milk and eggs for additional and less bulky protein we 
find an endless variety of menus which one may choose from, 
of which, the following are a few samples: 3 
Meat substitutes: 

Cheese souffle, corn and cheese, Welsh rarebit, baked 
cracker and cheese. Cheese rolls. Nut and cheese 
roast. Cheese and vegetable roll. Fried bread with 
cheese. Cheese ramequins. Cheese croquettes. 
Cheese fingers, etc. Macaroni and cheese. Rice 
and cheese. Rice, peas, beans and lentils. 
Macaroni and kidney beans. Chestnuts with hard 
sauce. Chestnut puree and mushroom. Boiled, 
creamed and broiled scalloped eggs and milk. 

1 Jour. Am. Med. Assn., lxiv, 17, 1425. 

2 Proc. Nat. Acad. Sc, 1915, i, 100. 

3 Gillmore: Meatless Cookery. 



SPECIAL DIETARY CURES 649 

Sample Breakfast Menus: 

Oranges; boiled rice; hashed browned potatoes; whole 

wheat gems; cocoa. 
Fruit; hominy; baked bananas; potato cakes; toasted 

white bread; cereal, coffee. 
Grapes; shredded wheat biscuit; fried tomatoes, corn 
cake; chocolate, etc. 
Luncheons: 

Asparagus on toast; stewed tomatoes; cottage cheese; 
prune fluff; spinach on toast; lettuce sandwiches; 
apple sauce; banana salad; rice soup; potato cro- 
quettes; tomato sandwiches; Malaga grapes. 
Dinner: 

Cream of vegetable soup; macaroni au gratin; mashed 
sweet potatoes; spinach; fruit salad; ginger pudding. 
Cream of potato soup; fried bananas; lima beans; 
mashed turnips; apple and celery salad; tapioca pud- 
ding. 
Tomato soup; new potatoes; cheese fritters; tomatoes; 
lettuce salad ; ice-cream. 
Fletcherism. — In the past, numberless propaganda of spe- 
cialized diet, methods of eating, water-drinking, and the thou- 
sand and one fads which sweep the community have all been 
brought forward and urged with the industry of the religious 
zealot. In many of them there is a certain amount of com- 
mon sense, and some patients are unquestionably helped, but 
many of the methods quickly fall into disrepute when they 
are found not to be beneficial to all alike. 

The system of dietetics, or possibly the philosophy of diet- 
etics, crystallized by Horace Fletcher, has stood more scien- 
tific investigation, with better results than almost any of 
them, and now has the enthusiastic support of many eminent 
men of science. 

"Fletcherism," as it is called, was formerly put down as a 
new fad with the most salient feature of excessive mastica- 
tion as the keynote, but Fletcher tells us 1 that this is not a 
true characterization of his method by any means, although 
he does recommend thorough mastication, which to rapid 
eaters certainly seems excessive. This method of eating 
was arrived at by personal experimentation after Fletcher 
had been rejected by a life insurance company as a bad risk, 
and the results in his case were surely successful, as he has 
repeatedly been able to undergo physical effort with less 
wear and tear than most of his younger contemporaries. 
The five principles upon which Fletcherism is founded are: 

1 Horace Fletcher: "Fletcherism:" What It Is. 



650 DIET IN MISCELLANEOUS CONDITIONS 

" I. Wait for a true, earned appetite. 

li 2. Select from the food available that which appeals 
most to the appetite and in the order called for by appetite. 

"3. Get all the good taste there is in food out of it in the 
mouth, and swallow only when it practically 'swallows 
itself.' 

"4. Enjoy the good taste for all it is worth and do not 
allow any depressing or diverting thought to intrude upon 
the ceremony. 

"5. Wait; take and enjoy as much as possible what appe- 
tite approves; Nature will do the rest." 1 

A great point is made of mouth digestion with fine com- 
minution of the food, giving the ptyalin a chance to act upon 
the starch and convert it as far as possible toward the ulti- 
mate maltose before swallowing it. The action of ptyalin 
is arrested by the acid in the gastric secretion and is only 
completed later in the intestine by pancreatic amylase. The 
discovery was made that if food is properly prepared for 
swallowing, it is difficult to keep from swallowing it, as the 
pharyngeal reflex is so strong. The same rule applies to 
liquids as to solids, and it is not so much a matter of what 
one eats, if one is hungry for it, as how one eats. 

Fletcher disposes of the common criticism that his method 
will upset the meal schedule of the best-regulated family by 
saying that a week's trial will determine how many meals a 
person should eat as a rule, two or three according to the 
amount of appetite, and the meals should be taken at a 
regular meal hour. 

If when a meal is due there is no appetite, wait until the 
next, and if appetite calls for food before it is due, this is 
usually easily quieted by a drink of water. After a time 
the new habits become second nature and the regulation of 
the meal hour presents no difficulty, as habit determines the 
new schedule, whether it be for one or more meals a day. 

The following method of attaining physiological economy 
in nutrition has been formulated by Fletcher and is included 
now in the Instructions to the Medical Department of the 
United States Army under the following heading : 

Method of Attaining Economic Assimilation of Nutri- 
ment and Immunity from Disease, Muscular 
Soreness and Fatigue. 

1. Feed only when a distinct appetite has been earned. 

2. Masticate all solid food until it is completely liquefied 
and excites in an irresistible manner the swallowing reflex or 
swallowing impulse. 

Ubid., p. 8. 



SPECIAL DIETARY CURES 651 

3. Attention to the act and appreciation of the taste are 
necessary, meantime, to excite the flow of gastric juice into 
the stomach to meet the food, as demonstrated by Pawlow. 

4. Strict attention to these two particulars will fulfill the 
requirements of Nature relative to the preparation of the 
food for digestion and assimilation ; and this being faithfully 
done, the automatic processes of digestion and assimilation 
will proceed most profitably and will result in discarding 
very little digestion-ash (feces) to encumber the intestines 
or to compel excessive draft upon the bodily energy for ex- 
cretion. 

5. The assurance of healthy economy is observed in the 
small amount of excreta and its peculiar inoffensive character, 
showing escape from putrid bacterial decomposition such as 
brings indol and skatol offensively into evidence. 

6. When digestion and assimilation have been normally 
economic, the digestion-ash (feces) may be formed into little 
balls ranging in size from a pea to a so-called Queen olive, 
according to the food taken, and should be quite dry, having 
only the odor of moist clay or of a hot biscuit. This inoffen- 
sive character remains indefinitely until the ash completely 
dries, or disintegrates like rotten stone or wood. 

7. The weight of the digestive-ash may range (moist) from 
10 grams to not more than 40 to 50 grams a day, according 
to the food; the latter estimate being based on a vegetarian 
diet, and may not call for excretion for several days; small- 
ness indicating best condition. Foods differ so materially 
that the amount and character of the excreta cannot be ac- 
curately specified. Some foods and conditions demand two 
evacuations daily. Thorough and faithful Fletcherizing 
settles the question satisfactorily. 

8. Fruits may hasten peristalsis ; but not if they are treated 
in the mouth as sapid liquids rather than as solids, and are 
insalivated, sipped, tasted, into absorption in the same way 
wine- tasters test and take wine, and tea- tasters test tea. The 
latter spit out the tea after tasting, as otherwise it vitiates 
their taste and ruins them for their discriminating profession. 

9. Milk, soups, wines, beer and all sapid liquids or semi- 
solids should be treated in this manner for the best assimila- 
tion and digestion as well as for the best gustatory results. 

10. This would seem to entail a great deal of care and 
bother, and lead to a waste of time. 

11. Such, however, is not the case. To give attention in 
the beginning does require strict attention and persistent 
care to overcome life-long habits of nervous haste ; but if the 
attack is earnest, habits of careful mouth treatment and 



652 DIET IN MISCELLANEOUS CONDITIONS 

appetite discrimination soon become fixed and cause delib- 
eration in taking food unconsciously to the feeder. 

12. Food of a protein value of 5 to 7 grams of nitrogen and 
1500 to 2500 calories of fuel value paying strict attention to 
the appetite for selection and carefully treated in the mouth, 
has been found to be the quantity best suited to economy 
and efficiency of both mind and body in sedentary pursuits 
and ordinary business activity; and also, such habit of econ- 
omy has given practical immunity from the common diseases 
for a period extending over more than fifteen years, whereas 
the same subject was formerly liable to periodical illness. 
Similar economy and immunity have shown themselves con- 
sistently in the cases of many test subjects covering periods 
of ten years, and applies equally to both sexes, all ages and 
other idiosyncratic conditions. 

13. The time necessary for satisfying complete body needs 
and appetite daily, when the habit of attention, appreciation 
and deliberation have been installed, is less than half an hour, 
no matter how divided as to number of rations. This neces- 
sitates industry of mastication, to be sure, and will not admit 
of waste of much time between mouthfuls. 

14. Ten to fifteen minutes will completely satisfy a raven- 
ous appetite if all conditions of ingestion and preparation 
are favorable. 

15. Both quantitative and qualitative supply of saliva are 
important factors; but attention to these fundamental re- 
quirements of right eating soon regulates the supply of all 
of the digesive juices, and in connection with the care re- 
commended above, ensures economy of nutrition and prob- 
ably immunity from disease. 

The results claimed by Fletcher for his method include 
attaining the optimum weight for the individual, freedom 
from muscular soreness after exercise, absence of fatigue and 
feeling tired, freedom from colds and the ordinary infections 
w T ith a continuous feeling of well-being. 

The results in certain cases at least are all Fletcher claims 
for them. 

Fruit Cures.— The use of fruits in disease is twofold, first 
as part of an invalid's general diet, and secondly as a specific 
cure for disease. 

On the score of the first it may be said that in most dis- 
eases, whether accompanied by fever or not, fruit in some 
form is almost always allowable unless there are digestive 
contra-indications and even in these cases fruit juices can 
usually be used. As a part of the diet it counts little for its 
food value and is ordinarily left out of account on that score,. 



SPECIAL DIETARY CURES . 653 

~but its refreshing qualities, vegetable acids and laxative 
effect, make fruit of great value in disease. If the fruit is 
ripe and easily digested it may be taken raw, but if otherwise 
is best cooked. About the only fruits that are not good for 
sick people are raw pineapples, very seedy fruit, or dried 
fruits. Naturally some people have an idiosyncrasy for 
certain fruits, and we find one patient cannot take bananas, 
another is made ill by strawberries and so on, but outside 
of such contra-indications, fruits may be taken freely, either 
whole or as fruit juices alone or mixed with water and sugar. 

When we come to examine the claims of the various fruit 
cures it is at once seen that whatever claims are made, the 
fact must be at once recognized that an exclusive fruit diet is 
an insufficient diet and that it is not a feasible way to nourish 
people, although a- certain amount of food may be furnished 
the system in this form. In the case of people who greatly 
overeat and are in consequence overweight and plethoric, a 
fruit cure does good by virtue of its low food value and its 
laxative effect, both of great assistance in such conditions. 

Grape Cure. — In this form of fruit cure popular abroad and 
in California among a few people, grapes are eaten in addi- 
tion to other food, beginning with a moderate amount and 
gradually increasing. In this manner two pounds of grapes 
are given at first as follows: One-half pound on waking — 
one-half pound at n a.m. another at 5 p.m.— still another at 
bedtime. This may be increased to three or four or even 
five pounds per day in some cases. As the diet is of low pro- 
tein content it is of use in renal insufficiency or in gout, on 
account of the " roughage;" it is helpful in constipation and 
again in obesity, if little other food is taken it results in re- 
duction on account of its low caloric value. 



CHAPTER XXXI.V. 

FOOD PROTECTION. ACCESSORY FOODS. 
BEVERAGES 

FLIES, FOOD AND ILLNESS. 

The relation between flies and sickness is too well-known 
to need much more than passing notice in a book on dietetics 
were it not for the fact that food, the third link in the chain, 
is all important, for by this vehicle, when infected by fly- 
carried bacteria, no end of damage may be done. That the 
house should be screened from flies, and particularly the 
kitchen, all food should be screened and all flies killed if they 
do gain admittance, goes almost without saying. In addi- 
tion to this they should be attacked in their breeding place, 
the manure piles of the country being the chief spots. This 
latter can be fairly effectively done if every day the fresh 
manure is well wetted down with a solution of from one- 
fourth to one pound of copper sulphate to the gallon of water, 
the stronger solutions killing 67 per cent., the weaker 57 per 
cent, of the maggots. Even better than this is the use of 
borax, i}4 pounds (dry) to 8 bushels of manure will kill 98 
to 99 per cent, of the maggots. Calcined colemanite, 2 pounds 
to 8 bushels, showed the same high percentage of larvicidal 
action. In addition the use of these latter substances have 
no ill effect on the manure for its future usefulness as a fer- 
tilizer. 1 

BEVERAGES FOR THE SICK. 

Flaxseed Tea: 2 

2 tablespoonfuls of flaxseed, \% tablespoonfuls of cream 
of tartar, 1 quart of boiling water, syrup and slices of 
lemon. 

Wash flaxseed, add water (boiling) and cream of tartar,, 
and allow to simmer until liquid is reduced a half. Strain r 
cool, add a little syrup, and serve with cut lemon. 
Orange- albumen Water:* 

White of 1 egg, 2 tablespoonfuls crushed ice, % cup 
orange juice, syrup. 

Beat the egg white, add orange juice, and syrup if needed. 
Strain over crushed ice. 

1 Plowman: Fighting the Fly Peril, p. 116. 

2 Farmer: Food Cookery for the Sick, p. 72. 3 Ibid. 

654 



BEVERAGES FOR THE SICK 65S 

Wine Whey: 1 

34 cup of milk, 3 tablespoonfuls sherry. 

Scald milk, add the wine, and let stand five minutes. 
Strain through cheesecloth (double) and serve. 
Egg lemonade: 2 

i egg, I tablespoonful sugar, 2 tablespoonfuls lemon 
juice, 34 cup cold water, 2 tablespoonfuls sherry, 2 table- 
poonfuls crushed ice. 

Beat eggs lightly, add water, sugar, lemon juice and 
wine. Strain over crushed ice. Not necessary to use the 
wine. 
Artificial Buttermilk or Ripened Milk: 

1000 c.c. (1 quart) fresh milk (fat-free for certain cases). 
Sterilize at 212 F. for twenty minutes. Cool to blood 
heat, 98 F., and pour into sterile bottles. Add proper 
amount of lactic acid bacillus culture (tablets or liquid). 
Stand for twenty-four hours at 95 F. Thoroughly beat 
with egg beater and put on ice. 
Irish Moss Jelly:* 

}4 cup Irish moss, lemon juice to taste, 1 cup water, 
syrup. 

Soak moss in cold water to cover, drain and pick over. 
Put in double boiler with one and one-half cups of cold 
water, cook for forty- five minutes and strain. 
Peptonized Milk* (cold process) : 

1 tube Fairchild's peptonizing powder (or any good 
preparation), Yi cup cold water, 1 pint milk. 

Dissolve powder in a little of the water, add the rest of 
the water, then the milk, shake and put on ice. 
Fully Peptonized Milk: 

Same as cold process, but put in clean bottle and stand 
in water at 115 F. for two hours, shaking occasionally 
and keeping temperature of water at 1 15 . When finished 
it should appear thin and have a slightly greenish-yellow 
tint. It should then be scalded and put on ice. If only 
partial peptonization is wanted, the process can be stopped 
at the end of ten, twenty or thirty minutes. 
Koumyss: 5 

1 quart milk, 34 yeast cake, 1 3^2 tablespoonfuls of sugar r 
1 tablespoonful lukewarm water. 

Heat milk to 75 F., add sugar and yeast cake dissolved 
in the warm water. Pour into sterilized beer bottles to 
within one and one-half inches of the top. Cool and 
shake. Put the bottles inverted where they can remain 

1 Farmer: Food Cookery for the Sick, p. 72. 2 Ibid. 

3 Ibid. 4 Ibid. 5 Ibid. 



656 FOOD PROTECTION— ACCESSORY FOODS 

at about jo° F., for ten hours, then put on ice and keep 
for forty-eight hours, shaking occasionally. 
Egg Nogg: 1 

\Yl tablespoonful sherry or i tablespoonful of brandy 
or rum, y A tablespoonful of sugar, few grains of salt, % 
cup cold milk. 

Beat egg slightly, add sugar, salt, and liquor, then 
gradually add milk. Strain and serve. 
Cocoa Shells: 2 

Yz cup cocoa shells, 2 cups boiling water. 

Boil the shells and water two hours, keep adding water 
as it boils away. Strain and serve with equal parts of hot 
milk, sugar to taste. 
Albumen Water: 7, 

White of 1 egg, }/& cup cold water. 

Stir egg with silver spoon or fork, this sets albumen 
free, add water. Strain and serve. If necessary, it may 
be flavored with fruit juices. 
Cereal Gruels 4 general directions : 

Use a double boiler. Keep correct proportions of re- 
ceipts. Cook at boiling temperature, 212 F. Serve 
daintily. 
Arrow-root Gruel: 5 

2 teaspoonfuls arrow-root, 2 tablespoonfuls cold water, 
1 cup boiling water, salt q. s., sugar, lemon juice, brandy 
or wine if required. 

Mix arrow-root and cold water to smooth paste, add 
to boiling water or milk. Cook in double boiler two hours. 
Salt, strain and serve. 205 calories. 
Barley Gruel:* 

1 tablespoonful barley flour, 2 tablespoonfuls cold milk, 
1 cup scalded milk, salt. 

Blend the barley with cold milk and stir into scalding 
hot milk. Cook in double boiler twenty minutes. Sea- 
son with salt, add sugar if desired. Strain. 248 calories. 
Flour Gruel: 1 

% cup scalded milk, 3^ tablespoonful flour, \i cup cold 
milk, speck of salt. 

Scald milk. Mix flour with cold milk to smooth mix- 
ture, stir in scalding hot milk. Cook in double boiler 
one-half hour, or on back of stove in saucepan. 212 
calories. 

1 Farmer: Food Cookery for the Sick, p. 72. 2 Ibid. 

3 Ibid. 4 Pattee: Diet in Disease, 1916, p. 236. 

■ 6 Ibid. 6 Ibid. 7 Ibid. 



/d /d '■d *"d l_ d 
3- p c o o 

2. co Cl.co rt 
CT*cn 3" 1 " 1 
- - (0 

CD p - 2 2. 
am re ^ ? 

11 IP' 

3-" 2 £. 

3 ^O CL 



t3 ^d *D T) 13 
o o a> p 

rt rt rt [0 1 
p P p CO Cfl 



n 



3 crcr 3 f» 
g o p - fe 

►rO (5 O — ■ 



2.2.3 S- 

o O » f+ 

w ^ 2 2 

O -- " 

X rt -J rs 
O w w 

rt - p 

0-rB w 



2 orq 3 

3 QfQ O 

rt- r" 

n 2- <t 

r* rt 



nnnnncdcdwtd 

Ortppprtrtrtrt 



- w E£-rt 



fed's 
SIS 3 
aT ci C. 

IS.* 

- <; p 

p rt crq 

3 P n 

p a> 
C/Q 



rt O-crBt 
2. o 



^ <T) ^ ft> CL 



w 



w 



OC; 



►n rti o o n o 

og^'OrtOrtO 
?r rt 3 ca <^o <-+. o 



O S4*y 



p - 
< p 

rt < 

3? 

orq p 

co crq 

rt 



rt- 3 

P O 



CO 



50 f» „, 

ro - < 

^ m (ti 
P Zt rt 

^ ^ P r, 

0) 5 Orq ^ 

p « p. 

°2 o 
o 


— 

CO 

— 






)td>> 
ro a» 2." 
P "O £;. 

3 P rt 

P m « 

D.P P 

3 5 2 
3 £> o 

'CO £f 3* 
rv P p 

p-p. 
P p 
3< 

p 3 

orq^ 
P rt 






3 "-t s^_^ 
^ o p 2", 

cr^r-"' p 

C.cT° ' 
o - >o 

3 <T> O . 
- 0-2> 

< So . 

CO CO 3 

Crq O S 
ft, -t S 



CO T3 

3 3 cr 

p . 3 



o 

3 
p". 

P . 
3 
r+ 
<T> 
-i ' 

O* 



r+« co 

3 Crq 

P 
< 



O . 



co ■ h: 

g. T3 

co o 

•a ' R 



SOOOOOOH 

p333t333^ 
— rO CO <"0 CO CO CO q 

O 3*5S p*^ ^ P — 



2L^ 

P s;<: crq 



b 2 3 p 
p. > -. crq 



o 



CD 



crq 2. 

re 3 
>0 orq 
O 

P 
rt- 

O 



N N 
CO CO 
0.0- 



crto • 
p rt> • 
— rt . 

CO 3 
rt orq 
< w 



^ nj 1-3 ^ r 1 c/3 

3-^-3-p-P 3 
rt en rt en rt ■— 



rt 



rt 



w 



% < % < cl a. 
<- 2«^ --rt n> 

5'crq 5'crq p- D- 
crq m crq w 00' So' 
w w 3- 3* 



SSS.J 
g p^< « 

en en rt 3 

^ 3 <Orq 

5.^.3" 

3 3 OK} 

orq Crq 



Ca) 00 00^. hOOOOOOOOi-^OhO OOCn Onv© -P^ 1-1 " hh -P>. 00-£- 00 N) ^J -P^ OJ 

O O O^MVO M ONCn WOOCnCnOOOivOOWCflOOiOCflO C\Oi O O 



OOOOOOOOOOOOOOOOOOOOOOOOOOOOOO 



GJ O ON-(^ w 
OJ O O W Cn 



OOOOO 



Cn^j to 1-1 OOJC^OJOoCn OO^J ^t OOOj W QOJvO 



00 rjN oc ctn-p^ to so c/i 



OO H O OCn O O OiOM G\^t 0\-£. On O O 
C^ On On-P^- On 



KJ OnOJ i-t 
Cn to 00-P* 



to to m^i to tOOo-vJ ONto-^-P^ to OnCti m ^. Cn OJ Cn W Oi Cn -P» 
OiCn^J^J-P^NO tOC^ OnO tOOi OOO On 00\O On 00 Q\ 004^ to OJ 



M^O h\0 m CM 

Cn to to 11 Cn vO 



O^OO 



OMOOCWO-^OOhOhhmO 



OO O'JiOOiO 



OJ to Cn Cn vO 

H MVJOM 



►HtOwtO •-( IO 1-1 >-i KJ 

CnN^O O OOCn Min w o 



C^-pi OOOnO OOOo OC-P^Cn^t OCOnOnOnOO^h O OC OOJ W W 



-p^ ^» Cn 00 



M O. 

to ^J 



OOOOOOOOOOOOOOOOOOOOOOOOOOOOOO 



o o c o o 



00000000000000000000000000000 



OOOOO 



On^J OOOOOj ONOOOCCn OC-pi 00 O 0\M vj vj v) vj O\0C^I^IGJ^tCs>^l OnOnOO 
G>nO MOiWCfl 0000OOJ Ooto hh hh tOC>» tO^J >-* to to toCn^JCn^JCn m to On 



M> O 

s 3 

aw 



cro 
o> o 

a 



OOOOOOO 



OOOOOOOOOOOOOOOOOOO 



smmsvsw gnv sihdizm "shiva aood zi9 



656 FOOD PROTECTION— ACCESSORY FOODS 

at about 70 F., for ten hours, then put on ice and keep 
for forty-eight hours, shaking occasionally. 
Egg Nogg: 1 

yYi tablespoonful sherry or 1 tablespoonful of brandy 
or rum, y A tablespoonful of sugar, few grains of salt, % 
cup cold milk. 

Beat egg slightly, add sugar, salt, and liquor, then 
gradually add milk. Strain and serve. 
Cocoa Shells: 2 

Yz cup cocoa shells, 2 cups boiling water. 

Boil the shells and water two hours, keep adding water 
as it boils away. Strain and serve with equal parts of hot 
milk, sugar to taste. 
Albumen Water: 1 

White of 1 egg, Yi cup cold water. 

Stir egg with silver spoon or fork, this sets albumen 
free, add water. Strain and serve. If necessary, it may 
be flavored with fruit juices. 
Cereal Gruels* general directions : 

Use a double boiler. Keep correct proportions of re- 
ceipts. Cook at boiling temperature, 212 F. Serve 
daintily. 
Arrow-root Gruels 

2 teaspoonfuls arrow-root, 2 tablespoonfuls cold water, 
1 cup boiling water, salt q. s., sugar, lemon juice, brandy 
or wine if required. 

Mix arrow-root and cold water to smooth paste, add 
to boiling water or milk. Cook in double boiler two hours. 
Salt, strain and serve. 205 calories. 
Barley Gruel:* 

1 tablespoonful barley flour, 2 tablespoonfuls cold milk, 
1 cup scalded milk, salt. 

Blend the barley with cold milk and stir into scalding 
hot milk. Cook in double boiler twenty minutes. Sea- 
son with salt, add sugar if desired. Strain. 248 calories. 
Flour Gruel: 7 

$4 cup scalded milk, Y tablespoonful flour, Y cup cold 
milk, speck of salt. 

Scald milk. Mix flour with cold milk to smooth mix- 
ture, stir in scalding hot milk. Cook in double boiler 
one-half hour, or on back of stove in saucepan. 212 
calories. 

1 Farmer: Food Cookery for the Sick, p. 72. 2 Ibid. 

3 Ibid. 4 Pattee: Diet in Disease, 1916, p. 236. 

* Ibid. 6 Ibid. 7 Ibid. 



ARTIFICIAL FOODS 657 

Farina Gruel: 1 

}/2 tablespoonful farina, M cup cold water, ]4, cup boil- 
ing water, ^ cup scalded milk, salt. 

Mix farina with cold water, add to the boiling water, 
and boil thirty minutes. Add scalding hot milk, salt q. s. 
A little sugar may be added, or an egg may be beaten and 
poured into it. 102 calories. 

ARTIFICIAL FOODS. 

The use of artificial foods is much more prevalent abroad 
than in America, and although they have a distinct field of 
usefulness, they are not so generally useful as one might 
think. One of their chief advantages is to reinforce natural 
foods when one wishes to give concentrated food of small 
bulk. 

Plasmon. — Plasmon is made from milk protein; it is a 
tasteless powder of white color, soluble in warm (but not 
hot) water, and is about 70 per cent, protein. 

Nutrose. — Nutrose is also a casein preparation, but com- 
bined with soda, making it easily soluble in water, represents 
about 90 per cent, protein. 

Somatose. — Somatose is made of meat digested, chiefly to 
albumoses, and is highly nutritious. 

Beef Meal. — Beef meal is prepared by digesting meat arti- 
ficially and is of high nutritive value — JJ per cent, protein, 
13 per cent. fat. It may be added to milk, soups, or milk 
preparations. 

Peptones. — Panopeptones, Witte's peptones. Armour's or 
Carnick's, vary from 1.5 per cent, to 10 per cent, nitrogen, 
and although concentrated foods, they are not practical for 
any but temporary use ; large amounts upset the stomach or 
produce diarrhea. 

Roberat. — Roberat is manufactured from the protein of 
wheat, corn, and rice. It is a purin-free food, or practically 
so, and may be used in gouty conditions, being added to 
other foods. 

Aleuronat. — Aleuronat is a vegetable flour, 80 to 90 per 
cent, protein, with 7 per cent, carbohydrate. This is used 
principally in making diabetic "near" bread, or is mixed 
with wheat flour in definite proportions, according to the 
carbohydrate tolerance. 

Tropon. — Tropon is a protein food made from fish and 
vegetables. This is sold separately or mixed with malt or 
chocolate, and since it is practically tasteless, it can be mixed 
with almost any food to reinforce it. 

1 Pattee: Diet in Disease, 1916, p. 236. 
42 



658 FOOD PROTECTION— ACCESSORY FOODS 

OLIVE OIL AND ITS DIETARY USAGE. 

Olive oil expressed from the ripe olive, either foreign or 
domestic (California), is largely used in medicine; in fact it 
is the basis of many of the oily medicinal preparations, and 
enters very considerably into the treatment of various dis- 
eases, principally of the digestive tract. As a general thing, 
when any part of the digestive canal is affected by lesions 
leading to stenosis in any degree, olive oil is a favorite remedy. 

Stenosis of the Esophagus. — Here olive oil is given in con- 
siderable quantities up to 4 ounces several times a day. al- 
ways before food is taken. In this way the tube is lubricated 
and soothed and the passage of suitable liquid or semiliquid 
food is facilitated. It also has a high caloric value as a food, 
and 4 ounces of it represents about 1000 calories; as much as 
this is not usually taken at one time, but may be. 

Pyloric Stenosis. — In pyloric stenosis either from a juxta- 
pyloric ulcer or from an old cicatrix, it does good in the same 
way, but in addition, like all oils, it has a marked effect in 
checking the flow of free hydrochloric acid. So in hyper- 
chlorhydria from whatever cause, olive oil is often useful for 
this latter reason. Its usefulness in ulcer is often great, 
particularly when this is associated with pylorospasm, and 
especially in such cases its control of gastric hyperacidity is 
marked. 

Gastric Dilatation. — In gastric dilatation dependent on 
narrowing at the pylorus, some relief is often obtained if the 
narrowing is due to spasm ; when there is a definite stricture 
from cicatricial tissue the most it can do is to allow the maxi- 
mum dilatation, in view of the actual narrowing, by the 
relief of irritation. 

Cholelithiasis. — For many years olive oil given on an 
empty stomach was a popular remedy for gall-stones, large 
numbers of which were said to have been passed by this 
method. On investigation the large numbers of so-called 
"gall-stones" have proved to be nothing more nor less than 
inspissated olive oil mixed with a little bile and intestinal 
contents. The oil is frequently passed in faceted small 
masses which on appearance seem to be gall-stones, but on 
further examination prove to be only the oil in this form. As 
a matter of fact, however, the pylorospasm often excited by 
cholelithiasis is relieved, so that the patient connects this 
relief with the passage of these false " gall-stones" and thinks 
himself cured. Olive oil also increases the flow of bile, and 
so does good in any condition of bile stasis. 

Gastric Hyperacidity. — The symptoms associated with 
gastric hyperacidity are frequently relieved by taking olive 



OLIVE OIL AND ITS DIETARY USAGE 659 

oil on an empty stomach prior to meals. This is due to the 
fact that oils and fats depress the flow of gastric juice, so 
actually reducing the acidity and consequently to some extent 
at least, the frequently associated pylorospasm. Ulcer of 
the stomach, so often a cause of gastric hyperacidity, is favor- 
ably influenced by a course of olive oil treatment, the oil 
being given before meals, beginning with 4 c.c. (1 dram) and 
increasing up to 15 c.c. {yi ounce) or even 30 c.c. (1 ounce). 
Some patients who cannot take oil before meals may take it 
directly afterward, when it also does good, but probably 
not to so great a degree. 

As a matter of fact it is to be regretted that all people can- 
not take olive oil, for many patients who might otherwise 
benefit from its use are unable to do so on account of a marked 
gastric disturbance, causing principally eructations and a 
disagreeable after-taste. In these persons peanut oil may 
be better tolerated and be just as effectual. In the same way 
an emulsion of sweet almonds may be equally efficient and 
is prepared as follows, according to Cohnheim: 

Blanch a dessertspoonful of sweet almonds and remove 
the skins, both being accomplished by boiling water. After 
being dried they are ground to powder and the powder added 
to a cup of boiling water. This is well rubbed with a spoon 
and strained through cheesecloth. About 200 c.c. of this; 
emulsion may be made from the dessertspoonful of almonds.. 
This should be slightly sweetened and taken before meals 
as one would olive oil. 



CHAPTER XXXV. 
TABLE OF FOOD VALUES, WEIGHTS AND MEASURES 

AVERAGE CHEMICAL COMPOSITION OF AMERICAN FOODS. 1 











Carbohy- 


Calories 


Food material. 


Water. 


Protein, 


Fat. 


drates. 


per 100 




Per cent. 


Per cent. 


Per cent. 


Per cent. 


gm.[ 


ANIMAL FOOD. 












A. Beef. 












Fresh: 












Chuck, including shoulder 


65.O 


19.2 


15-4 




222 


Loin .... 


61.3 


I9.0 


19. I 




255 


Sirloin butt, as purchased 


62.5 


19.7 


17.7 




246 


Porterhouse steak . 


60.O 


21.9 


20.4 




280 


Ribs ...... 


57-0 


17.8 


24.6 




302 


Round '. 


67.8 


20.9 


18.6 




I84 


Beef Organs: 












Brain ...... 


80.6 


8.8 


9-3 




122 


Kidney . . ... 


76.7 


16.6 


4.8 


0.4 


115 


Beef liver .... 


71.2 


20.4 


4-5 


1-7 


133 


Sweetbreads, as purchased 


70.9 


16.8 


12. 1 




l8l 


Tongue 


70.8 


18.9 


9,2 




163 


Cooked: 












Roast, as purchased 


48.2 


22.3 


28.6 




357 


Round steak, fat removed 


, 










as purchased 


63.O 


27.6 


7-7 




185 


Loin steak: 












Tenderloin, broiled . 


54-8 


23-5 


20.4 




287 


Canned: 












Boiled beef, as purchased 


• 5i-8 


25-5 


• 22.5 




3H 


Corned beef .... 


5i-8 


26.3 


18.7 




282 


Roast beef, as purchased 


58.9 


25-9 


14.8 




243 


B. Veal. 












Fresh: 












Breast 


68.2 


20.3 


11. 




185 


Leg ....... 


7i,-7 


20.7 


6-7 




146 


Loin 


69-5 


19 9 


10. 




174 


Rib 


69.8 


20.2 


9-4 




170 


Shoulder and flank, mediun 


1 










fat ..... . 


65.2 


19 -7 


14.4 




215 


Kidney, as purchased . 


75-8 


16.9 


6.4 




129 


C. Lamb. 












Fresh: 












Breast or chuck . 


. 56.2 


.19- 1 


23.6 




298 


Leg, hind 


58.6 


18.6 


22.6 




287 


Shoulder 


51-8 


18. 1 


29.7 




35i 


Forequarter .... 


• 55-i 


18.3 


25.8 




315 


Hindquarter .... 


. 60.9 


19.6 


19. 1 




258 


Cooked: 












Chops, broiled . 


• 47-6 


21.7 


29.9 




367 


Leg, roast .... 


. 67.1 


19.7 


12.7 




198 


1 From Atwater and Bryai 


it (Abstract, United 


States 


Department 


of Agri 



660 



A VERAGE CHEMICAL COMPOSITION OF FOODS 661 











Carbohy- 


Calories 


Food material. 


Water. 


Protein. 


Fat. 


drates. 


per 100 




Per cent. 


Per cent. 


Per cent 


Per cent . 


gm 


ANIMAL FOOD. 












D. Mutton. 












Fresh: 












Chuck, lean 


64.7 


17.8 


16.3 




225 


Leg, hind ...... 


63.2 


18.7 


17-5 




239 


Shoulder 


60.2 


17-5 


21.8 




274 


Forequarter . . . 


52.9 


15.6 


30.9 




352 


Cooked: 












Mutton, leg, roast . . 


50.9 


25.O 


22.6 




313 


E. Pork. 












Fresh: 












Ham 


50.1 


15-7 


33-4 


... 


375 


Pickled, salted, and smoked: 












Ham, smoked, boiled, as 












purchased .... 


5i -3 


20.2 


22.4 


. . . 


291 


fried, as purchased 


36.6 


22.2 


33-2 


. . . 


400 


Bacon, smoked .... 


20.2 


IO.5 


64.8 




646 


F. Sausage. 












(As purchased.) 












Bologna 


55-2 


18.2 


19-7 




258 


Frankfurt 


57-2 


19.6 


18.6 


I.I 


258 


Pork 


39-8 


I3.0 


44.2 


I . I 


468 


Sausage meat . 


46.2 


17-4 


32.5 




374 


G. Poultry. 












Fresh: 












Chicken, broiler .... 


69.7 


20.7 


8-3 




196 


young, dark meat 


70.1 


20.8 


8.2 




187 


light meat .... 


70.3 


21.9 


7-4 




184 


Duck, breast .... 


73-9 


22.3 


2-3 




151 


Guinea-hen meat, not includ- 












ing giblets 


68.9 


234 


6.5 




191 


Pheasant meat, not includ- 












ing giblets 


70.0 


24.7 


4.6 




180 


Pigeon meat, not including 












giblets 


632 


22.9 


12. 1 




243 


Quail meat, not including 












giblets 


66.3 


254 


7.0 




208 


Squab meat, not including 












giblets 


56.6 


18.5 


23-8 




324 


Turkey, dark meat . 


57-0 


21.4 


20.6 




3i6 


cooked 


53-7 


39-2 


4-3 




265 


light meat 


63 9 


25-7 


9-4 




235 


cooked 


58.5 


34-6 


4-9 




240 


Preserved Poultry Meat: 












Potted turkey .... 


56 . 


17.2 


22.0 




306 


chicken . . 


561 


19.4 


20.3 




306 


Canned chicken soup 


87.1 


2.9 


3-3 


5-1 


66 


gumbo soup 


91.0 


2.4 


0.2 


4.8 


35 


boned chicken 


57-6 


27.7 


12.8 




274 


H. Fish. 












Fresh: 












Cod, whole 


82.6 


16.5 


0.4 


1.2 


103 


Bass, black, whole . 


76.7 


20.6 


i-7 


1.2 


103 


sea, whole 


79-3 


19.8 


0.5 


1.4 


86 


striped, whole .... 


77-7 


18.6 


2.8 


1.2 


102 


Blackfish. whole . . 


70.1 


18.7 


1.2 


I.I 


80 



662 FOOD VALUE, WEIGHTS AND MEASURES 

















Carbohy- 


Calorie3 


Food material. 


Water. 


Protein. 


Fat. 


drates. 


per 100 




Per cent. 


Per cent. 


Per cent. 


Per cent. 


gm. 


ANIMAL FOOD. 












H. Fish. — Continued. 












Fresh: 












Bluefish, entrails removed 


78 5 ' 


19 4 


I .2 


I 3 


90 


Butterfish, whole 


70 





18 





II .O 


1 


2 


176 


Eels, salt water . 


7i 


6 


18 


6 


9-1 


I 





161 


Haddock, entrails removed 


81 


7 


17 


2 


0.3 


I 


2 


74 


Halibut, steak or sections 


75 


4 


18 


6 


5-2 


I 





125 


Herring, whole . 


72 


5 


19 


5 


7-i 


I 


5 


146 


Mackerel, whole 


73 


4 


18 


7 


7-i 


1 


2 


142 


Perch, white, whole . 


75 


7 


19 


3 


4.0 


I 


2 


ii7 


as purchased 


28 


4 


7 


3 


i-5 


O 


4 


44 


yellow, whole . 


79 


3 


18 


7 


0.8 


I 


2 


84 


Pickerel, pike, whole 


79 


8 


18 


7 


0.5 


I 


1 


81 


Pike, gray, whole 


80 


8 


17 


9 


0.8 


I 


1 


80 


Pompano, whole 


72 


8 


18 


8 


7-5 


1 





147 


Pogy (scup), whole . 


75 





18 


6 


5-i 


I 


4 


123 


Salmon, whole . 


64 


6 


22 





12.8 


I 


4 


209 


Shad, whole . . . ". 


70 


6 


18 


8 


9-5 


I 


3 


165 


roe, as purchased . 


7i 


2 


20 


9 


3-8 


I 


5 


133 


Smelt, whole .... 


79 


2 


17 


6 


1.8 


I 


7 


89 


Spanish mackerel, whole 


68 


1 


21 


5 


94 


I 


5 


175 


Trout, brook, whole 


77 


8 


19 


2 


2. 1 


I 


2 


98 


Preserved and canned: 














Cod, salt .... 


53 


5 


25-4 


03 




90 


Herring, smoked 


34 


6 


36.9 


15-8 






299 


Mackerel, salt, dressed . 


43 


4 


17-3 


26.4 






316 


Salmon, canned . 


63 


5 


21.8 


12. 1 






201 


Sardines, canned 


52 


3 


23.0 


19.7 






278 


Shellfish, etc., Fresh: 












Clams, round, removed fron 


1 










shell, as purchased 


80.8 


10.6 


1.1 


5-2 


75 


Oysters, solids, as purchasec 


1 88.3 


6.0 


13 


3-3 


5i 


Scallops, as purchased . 


• 80.3 


14.8 


O.I 


3-4 


76 


I. Eggs. 












Hens', uncooked 


73-7 


13-4 


10.5 




159 


boiled ..... 


73-2 


13.2 


12.0 






169 


whites .... 


86.2 


12.3 


0.2 






. 55 


yolks .... 


49-5 


15 -7 


33-3 






376 


Egg, boiled, I egg (50 gm. 


) 36.6 


6.6 


6.0 
Total, 


1 egg . 




169 

S3 


J. Dairy Products, etc. 












(As purchased.) 












Butter . . . . 


11. 


1 .c 


85.0 




795 


Buttermilk .... 


91.0 


3-0 





5 


4 


8 


36 


Cheese, American, pale 


3i-6 


28.8 


35 


9 





3 


453 


red 


28.6 


29.6 


3* 


3 






477 


California flat 


34-0 


24-3 


33 


4 


4 


5 


429 


Cheddar 


27.4 


27.7 


36 


8 


4 




473 


Cheshire 


37-1 


26.9 


30 


7 





9 


399 


Cottage 


72.0 


20.9 


1 





4 


3 


112 


Dutch 


35.- 2 


37-1 


17 


7 






3i6 


Full cream .... 


34-2 


25-9 


33 


7 


2 


4 


430 


Limburger .... 


42.1 


23.0 


29 


4 





4 


369 


Neufchatel .... 


50.0 


18.7 


27 


4 


1 


5 


337 


Roquefort .... 


29-3 


22.6 


29 


5 


1 


8 


375 


Swiss 


3i-4 


27.6 


24 


9 


1 


3 


443 


Cream 


74.0 


2.5 


18 


5 


4 


5 


201 


Koumyss . . 


• 89 


•3 


2 


.8 


2 


1 


5 


4 


53. 



A VERAGE CHEMICAL COMPOSITION OF FOODS 663 

















- Carbohy- 


Calories 


Food material 


Water. 


Protein. 


Fat. 


drates. 


per 100 




Per cent. 


Per cent. 


Per cent. 


Per cent. 


gm. 


ANIMAL FOOD. 












J. Dairy Products, etc.— 












Continued. 












Milk, condensed, sweetened 26.9 


8.8 


8-3 


54- 1 


335 


unsweetened (evapor 


- 










ated cream) . 


. 68.2 


9.6 


9-3 


II. 2 


172 


skimmed .... 


• 90.5 


3-4 


0.3 


5-1 


37 


whole 


. 87.0 


3-3 


4.0 


5-0 


72 


whey 


• 93 -o 


1.0 


0.3 


5-0 


28 


K. Miscellaneous. 












(As purchased.) 












Beef-juice .... 


• 93 .0 


4-9 


0.6 




25 


Calf's-foot jelly . 


. 77-6 


4-3 




17.4 


89 


Oleomargarine . . 


9-5 


1 .2 


83.0 




777 


VEGETABLE FOOD. 












A. Flour, Meals, etc. 












Barley meal and flour . 


11. 9 


10.5 


2.2 


72.8 


362 


Buckwheat flour 


13-6 


6.4 


1 .2 


77-9 


357 


Cornmeal, granular 




12.5 


9.2 


19 


75-4 


365 


Corn Preparations: 














Cerealine . 




10.3 


9.6 


1. 1 


78.3 


37o 


Hominy 








11. 8 


8-3 


0.6 


79 


364 


cooked 








79-3 


2.2 


0.2 


17.8 


84 


Oatmeal . 








7-3 


16. 1 


7.2 


67.5 


410 


• boiled . 








84-5 


2.8 


0.5 


«. 5 


63 


gruel 








91 .6 


1 .2 


0.4 


6-3 


34 


water . 








96.0 


0.7 


0. 1 


2.9 


15 


Rolled oats 








7-7 


16.7 


7-3 


66.2 


408 


Rice . . 








12.3 


8.0 


03 


79 


359 


boiled . 








72.5 


2.8 


0.1 


24.4 


112 


flaked . 








9-5 


7-9 


0.4 


81.9 


37i 


flour 








8-5 


8.6 


6.1 


68.0 


370 


Rye flour . 








12.9 


6.8 


0.9 


78.7 


359 


meal 








11. 4 


13-6 


2.0 


7i -5 


367 


Wheat, entire 








11. 4 


138 


i-9 


71.9 


369 


gluten . 








12.0 


14.2 


1.8 


71. 1 


367 


Graham 








11 3 


133 


2.2 


71-4 


368 


Prepared (self-raising) . 


10.8 


10.2 


1.2 


73-0 


353 


Wheat Preparations: 












Cracked and crushed 


10. 1 


11. 1 


i-7 


75-5 


37i 


Farina 


10.9 


11. 


1-4 


76.3 


37i 


Flaked 








8-7 


13-4 


1-4 


74-3 


373 


Gems . 








10.4 


10.. s 


2.0 


76.0 


374 


Glutens . 








8.9 


13-6 


1-7 


74.6 


378 


Macaroni 








10.3 


13 -4 


0.9 


74- 1 


367 


cooked . 








78.4 


3.o 


i-5 


15-8 


9i 


Noodles . 








10.7 


11. 7 


1 .0 


75-6 


367 


Shredded . 








8.1 


10.5. 


i-4 


77-9 


375 


Spaghetti 








10.6 


12 . 1 


0.4 


76.3 


366 


Vermicelli 








11 .0 


10.9 


2.0 


72.0 


358 


B. Bread, Crackers, Past] 


RY, 










etc. (As purchased.) 












Bread : 












Brown 


43-6 


5-4 


1.8 


47- 1 


231 


Corn (johnny cake) . 


38.9 


. 7-9 


4-7 


46.3 


266 


Rye 


35-7 


9.0 


0.6 


53-2 


260 


Wheat : 












Buns 


29.0 


6.3 


6-5 


57-3 


321 


Cinnamon . 


23.6 


9-4 


7.2 


59- 1 


347 


Currant 








27-5 


6-7 


7-6 


57-6 


334 



664 FOOD VALUE, WEIGHTS AND MEASURES 



















Carbohy- 


Calories 


Food material. Water. 


Protein. 


Fat. 


drates. 


per 100 


Per cent. 


Per cent. 


Per cent. 


Per cent. 


gm. 


VEGETABLE FOOD. 










B. Bread, Crackers, Pastry, 










etc. — Continued. 










Bread, Wheat: Hot cross . . 36.7 


79 


4.8 


49-7 


28l 


Graham 




35 


7 


8 


9 


1.8 


52 


1 


267 


Biscuit, home-made 




32 


9 


8 


7 


2.6 


55 


3 


287 


soda ..... 




22 


9 


9 


3 


13 -7 


52 


6 


381 


Rolls, French 






32 





8 


5 


2.5 


55 


7 


287 


Vienna . 






3i 


7 


8 


5 


2 .2 


56 


5 


287 


White, biscuit 






35 


2 


8 





i-4 


54 


3 


269 


home-made 






35 





9 


1 


1.6 


53 


3 


270 


all analyses 






35 


3 


9 


2 


i«3 


53 


1 


268 


Whole wheat 






38 


4 


9 


7 


0.9 


49 


7 


2.51 


Zwieback . 






5 


8 


9 


8 


9-9 


73 


5 


434 


Crackers: 










Soda .... . . 5.9 


9.8 


9-i 


73- 1 


424 


Boston (split) 






7 


5 


11. 


8.5 


71. 1 


416 


Egg . . . 






5 


8 


12.6 


14.0 


66.6 


454 


Graham . 






5 


4 


10. 


9-4 


73-8 


429 


Oatmeal . 






6 


3 


11. 8 


11. 1 


69.0 


434 


Oyster 






4 


8 


II-3 


10.5 


70.5 


433 


Pretzels . 






9 


6 


9-7 


3-9 


72.8 


375 


Saltines . 






5 


6 


10.6 


12.7 


68.5 


442 


Water . . 






6 


4 


11. 7 


50 


75-7 


405 


All analyses . 




6 


8 


10.7 


8.8 


71-9 . 


420 


Cake : 










Bakers' ... 31.4 


6-3 


4,6 


59-9 


302 


Chocolate layer 






20 


5 


6 


2 


8.1 


64 


1 


364 


Drop . 






16 


6 


7 


6 


14-7 


60 


3 


3i6 


Frosted 






18 


2 


5 


9 


9.0 


64 


8 


374 


Fruit . 






17 


3 


5 


9 


10.9 


64 


1 


388 


Gingerbread . 






18 


8 


5 


8 


9.0 


63 


5 


368 


Sponge 






15 


3 


6 


3 


10.7 


65 


9 


396 


Cookies, Cakes ; etc.: 










Molasses cookies . . 6.2 


7.2 


8.7 


75-7 


421 


Sugar cookies 




8-3 


7.0 


10.2 


73-2 


423 


Ginger snaps 






6-3 


6-5 


8.6 


76.0 


418 


Lady fingers . 






15.0 


8.8 


5-0 


70.6 


37i 


Macaroons 






12.3 


6-5 


1.5-2 


65 .2 


435 


Doughnuts . 






18.3 


6.7 


21.0 


53-1 


441 


Pie: 










Apple . ... . . 42 . 5 


3-1 


9.8 


42.8 


280 


Cream 






32.0 


4 


4 


11. 4 


51-2 


334 


Custard . 






62.4 


4 


2 


6-3 


26.1 


183 


Lemon 






47-4 


3 


6 


10. 1 


37-4 


262 


Mince 






4i-3 


5 


8 


12.3 


38.1 


294 


Squash 






64.2 


4 


4 


8-4 


21.7 


185 


Puddings: 










Rice custard .... 59-4 


4.0 


4.6 


31-4 


182 


Indian meal . 




60.7 


5 


5 


4.8 


27-5 


180 


Tapioca .... 




64-5 


3 


3 


3-2 


28.2 


159 


Tapioca with apple . 




70.1 





3 


0. 1 


29-3 


122 


Ice-cream 






66 


9 


5 


2 


10. 1 


17 


7 


189 



A VERAGE CHEMICAL COMPOSITION OF FOODS 665 



















Carbohy- 


Calories 


Food material. 


Water. 


Protein. 


Fat. 


drates. 


per 100 




Per cent 


Per cent. 


Per cent. 


Per cent. 


gm. 


VEGETABLE FOOD. 












C. Sugars, Starches, etc 












(As Purchased.) 












Candy 








96.O 


391 


Honey 




18 


2 





4 






81.2 


335 


Molasses, cane . 




25 


. 1 


2 


4 






69 -3 


284 


Starch, tapioca . 




11 


4 





4 







88.0 


364 


Sugar, coffee or brown 
















95 


389 


granulated 
















100. 


410 


maple 
















82.8 


339 


powdered .... 














100. 


410 


D. Vegetables. 












Artichokes, as purchased . 


79-5 


2.6 


0.2 


16.7 


80 


Asparagus, cooked, as pur 












chased . . 


91. 1 


2. I 


3-3 


2.2 


48 


Beans, butter, green 


58 


9 


9-4 


0.6 


29. 1 


163 


String beans, cooked 


95 


3 


0.8 


1. 1 


i-9 


21 


fresh, as purchased . 


83 





2. 1 


0.3 


6.9 


40 


Beets, cooked .... 


88 


6 


2-3 


0. 1 


7-4 


4i 


Cabbage 


91 


5 


1.6 


03 


5-6 


32 


Carrots, fresh .... 


88 


2 


1 . 1 


0.4 


9-3 


46 


Cauliflower, as purchased 


92 


3 


1.8 


0.5 


4-7 


3i 


Celery 


94 


5 


1. 1 


0. 1 


3-3' 


19 


Corn, green 


75 


4 


3-1 


1 . 1 


19.7 


104 


Cucumbers 


95 


4 


0.8 


0.2 


3i 


18 


Eggplant 


92 


9 


1.2 


03 


5-i 


29 


Greens, beet, cooked, as pur 














chased 


89 


5 


2.2 


34 


3-2 


54 


Lentils, dried, as purchased 


8 


•4 


25-7 


1 .0 


59-2 


357 


Lettuce 


94 

88 


7 

1 


1 .2 


0.3 

0.4 


29 

6.8 


20 


Mushrooms, as purchased 


3-5 


46 


Okra 


90 

87 


2 


1.6 


0.2 


7-4 
9-9 


39 
49 


Onions, tresh .... 


6 


1.6 


0.3 


prepared, as purchased . 


91 


2 


1.2 


1.8 


4-9 


42 


Parsnips ..... 


83- 





1.6 


0.5 


13-5 


66 


Peas, dried, as purchased . 


9 


5 


24.6 


1.0 


62.0 


365 


green 


74 


6 


7.0 


0-5 


16.9 


102 


cooked, as purchased 


73 


.8 


6-7 


3-4 


14.6 


119 


Potatoes, raw or fresh cookec 


1 78 


3 


2.2 


0. 1 


18.4 


85 


boiled, as purchased 


75 


5 


2-5 


0. 1 


20.9 


97 


cooked chips, as purchasec 


1 2 


2 


6.8 


39-8 


46.7 


589 


mashed and creamed, a 














purchased . 


75 


1 


2.6 


30 


17.8 


in 


sweet, raw or fresh . 


69 





1.8 


o-7 


27-4 


126 


cooked and prepared, a 














purchased . 


5i 


9 


3-0 


2.1 


42.1 


204 


Pumpkins 


93 


1 


1 .0 


0. 1 


5-2 


26 


Radishes 


9i 


8 


i-3 


0. 1 


5-8 


30 


Rhubarb 


94 


4 


0.6 


0.7 


3-6 


23 


Sauerkraut, as purchased . 


88 


.8 


1.7 


05 


3-8 


28 


Spinach, fresh, as purchased 


92 


•3 


2. 1 


03 


3-2 


24- 


cooked, as purchased 


89 


.8 


2. 1 


4-1 


2.6 


57 


Squash ....... 


88 


•3 

•3 


i-4 
0.9 


0.5 
0.4 


9.0 
3-9 


47 
23 


Tomatoes, fresh, as purchasec 


i 94 


Turnips 




89 


6 


1 


3 





2 


8.1 


4i 



666 FOOD VALUE, WEIGHTS AND MEASURES 



Food material. 

VEGETABLE FOOD. 

D. Vegetables. — Continued 

Canned as Purchased. 
Asparagus . 
Beans, baked 

string . 

lima . 

red kidney 
Brussels sprouts 
Corn, green 
Okra 

Peas, green 
Pumpkins 
Squash . 
Succotash 
Tomatoes 

F. Fruits, Berries. 
Apples : 

Edible portion .... 

As purchased (refuse, 25.0) 

Apricots 

Bananas: 

Edible portion .... 

As purchased (refuse, 35.0) 
Blackberries, as purchased ' . 
Cherries, as purchased 
Cranberries, as purchased 
Currants, as purchased 
Figs, fresh, as purchased . 
Grapes, as purchased . 

Huckleberries 

Lemons: 

Edible portion . . . . 

As purchased (refuse, 30.0) 
Muskmelons: 

Edible portion .... 

As purchased (refuse, 50.0) 
Nectarines . . . , 
Oranges: 

Edible portion .... 

As purchased (refuse, 27.0) 
Peaches : 

Edible portion .... 

As purchased (refuse, 18.0) 
Pears : 

Edible portion . . . "... 

As purchased (refuse, 10.0) 

Pineapple 

Prunes 

Raspberries, as purchased 
Strawberries . . . . 
Watermelons : 

Edible portion .... 

As purchased (refuse, 59.4) 

Dried. 
Apples, as purchased . 
Apricots, as purchased 
Citron, as purchased . 



Water. 
Per cent. 



94-4 
68.9 



93- 
79- 
72. 

93 

76. 

94- 

85. 

9i 

87.6 

75-9 
94.0 



84 
63 

85 

75 
48 
86 
76 
88 
85 
79 
58 
81 

89 
62 

89 
44 

82 

86 
63 

69 
73 

64 
76 

89 
79 
85 
90 

92 

37 



Protein. 
Per cent. 



i-5 
6.9 



1.1 

4.0 



28.1 
29.4 
19.0 



0.8 
0.9 
3-6 
1.2 



04 
0.3 
1.1 

i-3 

0.8 

i-3 

0.9 
0.4 
1-5 
1-5 
1.0 
0.6 

1.0 

0.7 

0.6 

0.3 
0.6 

0.8 
0.6 

0.7 

0.5 

0.6 

0.5 
0.4 
0.9 
1.0 
1.0 

0.4 

0.2 



1.6 
4-7 
05 



Fat. 
Per cent. 



O.I 

2-5 
o. I 

0.3 

0.2 
0.1 
1.2 
O. I 
0.2 
0.2 

0.5 
I.O 
0.2 



Carbohy- Calories 
drates. per 100 
Per cent. gm. 



0.5 
0.3 



I .2 
0.6 

0.7 
05 



0.2 
O. I 

O.I 
O. I 

0.5 
0.4 

0.3 



0.6 

0.2 

O. I 



2.2 
I.O 
1-5 



2.8 

19.6 

3-8 
14.6 

18.5 

34 
19 

3 

9 

6 

10 

18 
4 



14.2 
10.8 
13-4 

22.0 

14-3 
10.9 

15 9 
9-9 

12.8 
18.8 
14.4 
16.6 

8-5 
5-9 

9-3 
4.6 

15-9 

11. 6 

8-5 

9-4 

7-7 

14. 1 
12.7 

9-7 
18.9 
12.6 

7-4 

6-7 

2.7 



66.1 
62.5 

78.1 



19 

132 

21 

79 

106 

21 

103 

19 

56 

33 

52 

103 

23 



64 
49 

59 

101 

66 
15 
76 
47 
58 
84 

74 
76 

45 

32 

41 
20 

67 

53 
37 

42 
34 

65 

57 
44 
81 

56 
40 

3i 
13 



298 
284 
336 



A VERAGE CHEMICAL COMPOSITION OF FOODS 667 











Carbohy- 


Calories 


Food material. 


Water. 


Protein. 


Fat. 


drates. 


per 100 




Per cent. 


Per cent. 


Per cent. 


Per cent. 


gm. 


VEGETABLE FOOD. 












F. Fruits, Berries, etc. — 












Continued. 












Currants, as purchased 


17.2 


2.4 


17 


74.2 


330 


Dates 


• 15-4 


2. I 


2.8 


78.4 


336 


Tigs, as purchased .... 


18.8 


4-3 


0.3 


74.2 


325 


Pears 


16.5 


2.8 


5-4 


72.9 


360 


Prunes 


22.3 


2 . 1 




73-3 


309 


Haisins 


14.6 


2.6 


3-3 


76.1 


354 


Canned and Jellies. 












Preserves, etc., as purchased: 












Apples, crab 


42.4 


0.3 


2-4 


54-4 


247 


sauce 


6l. I 


0.2 


0.8 


37 


2 


161 


Apricots 


81.4 


0.9 




17 


3 


75 


Blackberries 


40.0 


0.8 


2. 1 


56 


4 


254 


Blueberries 


85.6 


0.6 


0.6 


12 


8 


61 


Cherries 


77.2 


1 .1 


0. 1 


21 


1 


9i 


Figs, stewed ... 


56.5 


1 .2 


0.3 


40 


9 


173 


Marmalade (orange peel) 


14-5 


0.6 


0. 1 


84 


5 


349 


Peaches 


88.1 


0.7 


0. 1 


10 


8 


49 


Pears 


81. 1 


03 


03 


18 





78 


Strawberries, stewed 


74.8 


0.7 




24 





101 


Prune sauce 


76.6 


05 


0. 1 


22 


3 


95 


G. Nuts. 












Almonds . . . 


4.8 


21 .0 


54-9 


17-3 


668 


Beechnut 


4.0 


21.9 


57-4 


13.2 


678 


Brazil nuts (Bertholletia ex- 












celsa), edible portion 


5-3 


17.0 


66.8 


7.0 


720 


Butternuts: 












Juglans cinerea .... 


4-4 


27.9 


61.2 


3-5 


698 


Chestnuts: 












Edible portion .... 


45-0 


6.2 


5-4 


42.1 


246 


As purchased (refuse, 16.0) 


37-8 


5-2 


4 5 


35 ■ 4 


208 


Cocoanuts 


14. 1 


5-7 


50.6 


27.9 


608 


Cocoanut, prepared, as pur- 












chased 


3-5 


6-3 


57-4 


31-5 


689 


Filberts 


3-7 


156 


65-3 


130 


725 


Hickory nuts 


3-7 


154 


674 


11. 4 


737 


Lichi nuts 


17 9 


2.9 


0.2 


77-5 


332 


Peanuts: 












Edible portion .... 


9.2 


25-8 


38.6 


24.4 


564 


As purchased (refuse. 24.5) 


6.9 


19 -5 


29. 1 


18.5 


427 


Peanut butter, as purchased . 


2. 1 


293 


46.5 


17. 1 


623 


Walnuts, California 


2-5 


18.4 


644 


130 


728 


H. Miscellaneous. 












Chocolate 


5-9 


12.9 


48.7 


30.3 


631 


Cocoa 


46 


21.6 


28.9 


37-7 


5 11 


UNCLASSIFIED FOOD 












MATERIALS. 












Animal and Vegetable. 












A. Soups. 












Home-made (as purchased). 












Beef 


92.9 


4-4 


0.4 


1 . 1 


26 


Bean 


84-3 


3-2 


1-4 


9 


4 


65 


Chicken ....... 


84-3 


10.5 


0.8 


2 


4 


61 


Chowder, clam 


88.7 


1.8 


0.8 


6 


7 


43 


Meat stew 


84-5 


4.6 


4-3 


5 


5 


81 



668 FOOD VALUE, WEIGHTS AND MEASURES 















■ 


Zarbohy- 


Calories 


Food materia . 


Water. 


Protein. 


Fat. 


drates. 


per 100 




Per cent. 


Per' cent 


Per cent. 


Per cent. 


gm. 


UNCLASSIFIED FOOD 












MATERIAL. 












A. Soups. — Continued. 












Canned (as purchased) 














Asparagus, cream of . 




87.4 


2-5 


3.2 


5 5 


63 


Bouillon 






96 


6 


2.2 


O. I 





2 


II 


Celery, cream of 






88 


6 


2. I 


2.8 


5 





55 


Chicken .... 






93 


8 


3-6 


0. I 


1 


5 


22 


gumbo 






89 


2 


3-8 


0.9 


4 


7 


43 


Consomme . 






96 





2-5 







4 


12 


Corn, cream of . 






86 


8 


2.5 


1.9 


7 


8 


59 


Julienne .... 






95 


9 


2.7 







5 


13 


Mock turtle 






89 


8 


5-2 


0.9 


2 


8 


4i 


Mulligatawny . 






89 


3 


3-7 


0. I 


5 


7 


40 


Oxtail 






88 


8 


4.0 


i-3 


4 


3 


46 


Pea . ... . . 






86 


9 


3-6 


0.7 


7 


6 


52 


cream of green . 






87 


7 


2.6 


2.7 


5 


7 


60 


Tomato .... 






90 





1.8 


1 . 1 


5 


6 


4i 


Turtle, green 






86 


6 


6.1 


i-9 


3 


9 


58 


Vegetable 




95 


7 


2.9 







5 


14 


B. Miscellaneous. 












Hash . ... . . . 


80.3 


6.0 


■ 19 


9-4 


80 


Mincemeat, commercial 




27 


7 


6-7 


i-4 


60.2 


288 


home-made . 




54 


4 


4.8 


6-7 


32.1 


214 


Salad, ham .... 




69 


4 


15-4 


7-6 


5-6 


157 


Sandwich, egg . 




4i 


4 


9,6 


12.7 


34-5 


299 


chicken .... 




48 


5 


12.3 


54 


32.1 


232 


Table ( 


)F Measures ani 


> Weights. 






4 saltspoonfuls 


.= 




1 teaspoonful 






3 teaspoonfuls 


= 




1 tablespoonfn 






4 tablespoonfuls 


= 




Y A cup or y 2 gi 


11 




1 6 tablespoonfuls (dry) 


= 




1 cup 






16 tablespoonfuls (wet) 


= 




1 cup 






2 gills 


= 




1 cup (8 oz. or 


250 c.c.) 




2 cups 


= 




1 pint (16 oz. or 500 c.c 


) 


2 pints 


= 




1 quart (32 oz. 


or 1000 c.c.) 


4 quarts 


= 




1 gallon (128 oz. or 4000 c.c.) 


2 tablespoonfuls butter 


= 




1 ounce (30 gm 


•) 




4 tablespoonfuls flour 


= 




1 ounce (30 gm 


• ) 




2 tablespoonfuls granul' 


d sugar = 




1 ounce (30 gm 


•) 




2 tablespoonfuls liquid 


= 




1 ounce (30 c.c 


) 




5 tablespoonfuls liquid 


= 




1 wineglassful 






Apc 


)THECARIES 


' Measures. 






6o minims (M) 


= 




1 fluidram (4 c.c.) 




8 fluidrams 


= 




1 fluidounce (30 c.c.) 




1 6 fluidounces 


= 




1 pint (500 c.c. 


) 




2 pints 


= 




1 quart (1000 c.c.) 




4 quarts 


= 




1 gallon (4000 < 


:.c.) 




Apothecaries' Weights. 






20 grains 


= 




1 scruple (\y z gm.) 




3 scruples 


= 




1 dram (4 gm.) 






8 drams (480 grains) 


= 




1 ounce (30 gm 


•) 




12 ounces 


= 




1 pound (360 g 


m.) 




Ap 


PROXIMATE 


Measures. 






1 teaspoonful 


= 


about 


1 fluidram (4 c 


c) 




1 dessertspoonful 


= 




2 fluidrams (8 ( 


i.e.) 




1 tablespoonful 


= 




4 fluidrams (15 


c.c.) 




1 wineglassful 








" = 




2 ounces (60 c.c.) 







A VERAGE CHEMICAL COMPOSITION OF FOODS 669 



Relative Value of Metric and Apothecaries' Measure. 



Cubic Fluid - 
.centimeters, ounces. 



IOOO = 
•QOO = 

.800 = 
760 = 



33-8i 
30 -43 
27.05 
23,67 



600 = 20.29 
500 = 16.90 
473 = 16.00 



Cubic cen- Fluid- 
timeters. ounces. 



400 = 
300 = 
200 = 
100 = 

75 = 
50 = 
30 = 



13-53 
10.14 
6.76 
3-38 
2-53 
1.69 
1. 01 



Cubic Fluid- 
centimeters, drams. 



25 = 6.76 
IO = 2.71 

9=2. 

8=2. 

7=1. 
6=1. 
5=i- 



43 
16 

89 
62 

35 



Cubic 
centimeters. 



Minims. 



4.OO = 64.80 

3 . oc = 48 . 60 
2 . 00 = 32 . 40 
1. 00 = 16.23 
0.50= 8. 11 
0.25 = 4.06 
o . 06 = 1 . 00 



Relative Value of Apothecaries' and Metric Measure. 



Cubic cen- 
.Minims. timeters. 

1 = 0.06 

2 = O.I2 

3 = 0.18 

4 = 0.24 

5 = 0.30 

6 = 0.36 

7 = 0.42 

8 = 0.50 
9= 0.55 

10 = 0.60 
J 1 = 0.68 

12 = 0.74 

13 = 0.80 
14= 0.85 

15 = 0.92 

16 = 1. 00 
17= 1.05 

18 = 1. 12 

19 = 1. 17 

20 = 1 . 25 
25 =i-54 



Cubic cen- 
Minims. timeters. 

30 = I.90 

35 = 2.16 

40 = 2.50 

45 = 2.80 

50 = 3 08 

55 = 3-40 



Fluid- Cubic 
ounces, centimeters. 



Fluid- 
drams 
1 

iX = 

iK = 
iX = 
2 

3 = 

4 = 

5 = 

6 = 



3-75 
4-65 
5.60 

6.51 
7-50 
11.25 
15.00 
18.50 
22.50 
26.00 



1 = 

2 = 

3 = 

4 = 

5 = 

6 = 



30.00 

59.20 

89.00 

118.40 

148.00 

178.00 

7 = 207 . 00 

8 = 236.00 

9 = 266.00 
10 = 295.70 

12 = 355-00 

13 = 385 00 

14 = 414.00 

15 = 444.00 
16= 473-H 

17 = 503-00 

18 = 532.00 

19 - 591-50 



Fluid - 
ounces. 



23 
24 
25 
26 
27 
28 
30 
31 
32 
48 
56 
64 
72 
80 
96 
112 
128 



Cubic 
centimeters. 

= 62I.OO 

= 650.OO 

= 680 . 00 

= 7IO.OO 

= 74O . OO 

= 769 . 00 

= 798 . 07 

= 828.80 

= 887.25 
= 917.00 

= 946 . 00 
= 1419.00 
= 1655-00 

= 1892.00 
= 2128.00 
= 2365.00 
= 2839.00 
= 3312.00 
= 3785 00 



Relative Value of Metric and Avoirdupois Weight. 



Grams. 

28.35 
29.OO 
30.00 
32.00 

33 00 
34.00 
35 00 
36.00 
37-00 
38 . 00 
39.00 
40.00 
50.00 
60.00 
70.00 
80.00 
85.00 

TOO. 00 



Ounces. Grains. 



25 
56 
72 
87 
103 
Il8 

133 
149 
164 
180 
334 
50 
205 
300 



+ 230 



Grams. 


{ 


Dunces 




Grains 


I25.O 


= 


4 


+ 


179 


I50.O 


= 


5 


+ 


127 


200.0 


= 


7 


+ 


24 


25O.O 


= 


8 


+ 


358 


300.0 


= 


10 


+ 


255 


350.0 


= 


12 


+ 


152 


400.0 


= 


14 


+ 


48 


500.0 


= 


17 


+ 


279 


550.0 


= 


19 


+ 


175 


60O.O 


= 


21 


+ 


72 


65O.O 


= 


22 


+ 


405 


700.0 


= 


24 


+ 


303 


750.0 


= 


26 


+ 


198 


800.0 


= 


28 


+ 


96 


85O.O 


= 


29 


+ 


429 


900.0 


= 


31 


+ 


326 


950.0 


= 


33 


+ 


222 


1000.0 


= 


35 


+ 


120 



670 FOOD VALUE, WEIGHTS AND MEASURES 

Relative Value of Avoirdupois and Metric Weight. 



Avoirdu- 




Grams. 


pois ounces. 






% 


= 


1.772 


n 


= 


3 ■ 544 


x 


= 


7.088 


X 


= 


14-175 


i 


= 


28.35 


2 


= 


56.70 


3 


= 


85.05 


4 


= 


113.40 


5 


= 


141 -75 


6 


= 


170. 10 


7 


= 


198.45 


8 


= 


226.80 


9 


= 


255-15 


10 


= 


283.50 


ii 


= 


311-84 


12 


= 


340.20 


13 


= 


368.54 


14 


= 


396.90 


15 


= 


425-25 


Avoir 


pounds. 



Avoirdu- 






pois pounds. 


Grams. 


I .O 


= 


453 • 60 


2.0 


= 


907.18 


2.2 


= 


IOOO.OO 


SO 


= 


1360.78 


4.0 


= 


I8I4-37 


5-0 


= 


2267.55. 


6.0 


= 


2721.55 


7.0 


= 


3175- 14- 


8.0 


= 


3628.74 


9.0 


= 


4082.33. 


10. 


= 


4535-92- 



Relative Value of Apothecaries' and Metric Weight. 



Grains. 




Grams. 


Grains. 


Grams. 


Drams. 


Grams. 


1.0 


= 


O.0625 


24 


= 


i-55 


I 


= 


3-90 


2.0 


= 


0. 1300 


25 


= 


1.62 


2 


== 


7.80 


3-0 


= 


0.1950 


26 


= 


1.70 


3 


= 


H.65 


4.0 


= 


O.2600 


27 


= 


i-75 


4 


= 


15 -50 


5-0 


= 


O.3240 


28 


= 


1.82 


5 


= 


19.4a 


6.0 


= 


. 4000 


30 


= 


i-9'5 


6 


= 


23.30 


7.0 


= 


O . 460O 


32 


= 


2.10 


7 


= 


27.20. 


8.0 


= ' 


O.52OO 


33 


= 


2.16 


Ounces. 




9.0 


= 


. 6000 


34 


= 


2:20 


1 


= 


3I.IO 


10. 


= 


O.65OO 


35 


= 


2.25 


2 


= 


62.20 


11. 


= 


0.7I50 


36 


= 


2.3b 


3 


= 


93-30 


12.0 


= 


O.780O 


38 


= 


2-47 


4 


= 


124.40 


14.0 


= 


O.907O 


39 


= 


2-55 


5 


= 


I55-50 


15.0 


= 


O.972O 


40 


= 


2-73 


6 


= 


186.60 


15-5 


= 


I . OOOO 


44 


= 


2.86 


7 


= 


217.70 


16.0 


= 


I . 0400 


48 


= 


3-00 


8 


= 


248 . 80 


18.0 


= 


I . 1600 


50 


= 


3-25 


9 


= 


280.00 


20.0 


= 


I . 30OO 


52 


= 


3-40 


10 


= 


311.00 


21.0 


= 


I . 3600 


56 


= 


3.65 


48 


= 


1492.80 


22.0 


— 


I.425O 


58 


= 


3-75 


100 


= 


3110.40 



Relative Value of Metric and Apothecaries' Weight. 



G? ams. 


Grains. 


I = 


15-43 


2 = 


30.86 


3 = 


46.30 


4 = 


61-73 


5 = 


77.16 


6 = 


92.60 


7 = 


98.02 


8 = 


123.46 



Grams. 




Grains. 


9 


= 


138.90 


10 


= 


15432 


100 


= 


I543.23 


125 


= 


1929.04 


150 


= 


2374.85 


175 


= 


2700.65 


1000 


= 


15432.35. 



A VERAGE CHEMICAL COMPOSITION OF FOODS 671 



• 5 J£ 


J 81 




■i*S 8 


u rt « 




°,8.S 




Sfdifd 


c'52-2 


y 2 >»o 


v ca a 


& 



.5 - rt 
WW o 

g rt o 

«*, >> 

o-go 



< 



.s?S 



3§ 



•2-a 

•a rt 



4/ O 



t3 2 



S5 



ob 



rt"0 
Ob 



3 03 

O M 
U 3 



oooooo -oooooooo 
o o o io^a> ■ n\ooio*«nn 



OOOOOOOOOOOOO 



ooooooooooooooo 

O 6 O iONh On CO ■* O lO ■**- On rO CO 
rj- OnvO PI M fin M pi <tt^M m pin 



ooooccoooooooooooo 



i-i t^OO h ^-t<5 . tj- O COM3 IO00 rf iO 



CNNNfOC iocn r^<N rj- c ^- on m iooo o< r^ 



hh m (\) i-i ^ rooo 'tX X m n Tj-t^Cs 
Csr^'- 1 r^u^iOT^-t^iCi^OO rt- r^- rO <0 



^OMOMNNvOOMOiCOC 
On W t^ On co 



N f^ IC ic 
4 



CO N nO 

1-1 N M 


P) 


M 


d 


O On oncc 


N 


cOnO On 
r^ On On ^)" 

O O O <N 














c 


o 


o o o o 


o 


io o 


o 


IC 



00 CO ThOO WNOW't^XXXHOXXO 

WMMHMMTJ-^N^OPIN'tNHOO 



oooocoocoooocccooo 



OO C CN r*JN XT. o OX lO — OnI^I^O fCN 
lOt-O-t-mNC'O onCn— rONX r^« 1/3 ir, on M 

C^ N M l-l l-l 



bfl be bfl bfl be oj 

3 3 C 3 C m 

*>">'>'>'> = 

U QJ 1) CI CJ C 

M o in tn to « 

£ as £ £ £ <y 

C/) h3 tf) C/3 en > 



bfl 

a.S 

l>2>bflbcbAbflbfl 
^ U D.- .5.5.5 .5 

CB_ «>>>>> 

~ ^ )- v- i* i* u 

^D D J) 4) 4) 
M (C 91 10 * 



bfl bfl bfl 

3 c c 



bfl 

bfl 3 



bfl bfl .3 



- 



-Mcflc<u = — 3: ^ 
33j~rt335rt 

OOOJ^'/xJ 



Oen 



C 

-a -5 -a 



- 
c 

rt 



.3 x 

> o 



:; 13 '_3 bfl nj o u- 



m ^ en x r* r* 

bflbo^ 8 b^£ 5 

a><yS5c«PjflO 



° ° 

^hrEOHhOOO 



<y £ 



> o 

nj bo 






^-v c "O tc 
Jd _0) p O 

*0 T3 T3 J2 

II3H1 

u u u <£ 



3 -a 5 "SoS- : 

^J "S-a'SJ 



rsxi 



U a 



■g rt o bfl^ £ £ 



a « a, 

O w - 

^ «- 3 
X3 



bfl 
bfl u 



"tiOi c "3 



1) D D D D D 
0) <D 1) <1J OJ <U 

CC 2Q 2Q CC PC 03 



c3-C'a3 rt^ O O 



^ - 
- bfl 

^!— r 
3 rt 

3 OJ 



,= 3 3 

o'o'o 



or - 

■Z O 3 

^5 8- 

"03*0 

3 QJ <U 

rt— ' ~ 

"""^ 3 in 

' a § g> g 

33 § §'£ 



bfl > 



O 

bfl-£ 

-5 



m O rt 
bfl\£ - 
rt i- 3 
1-00 

6/0 Si <u v - 

2*3 a 

-3- 



a> ^ o 
bfl bx.2 

0,0 

> > a 
rt °!^ 
- S? 

o P-3 



3 t ---d oiH^ 



X5 r ti "re rt a)-s»cJBJS «J 



rt 



o ■ 



1) 0) u 



D O D D 4) 1) D 
i) 1) 1) 1) 1) 1) W 



£ s xi <y o 

•gT3 <U bfl^ 
r c - 3 rt 

^o3$»S — ^' s c 3 

'S » ^ a; %^% S Q ~ 



- M m w - M *g . 



fflfflCQaQfflpQPQUUUOffij^S^CP-C- 



672 FOOD VALUE, WEIGHTS A ND ME A S URES 









2 "cs ° 



c-£c 
SS-2 

sea 






.C O 

o a 

02 _ 



C >» 

■s-§ 

o-? 



o-o 

e rt 



IS 



c o 
o73 



sS 






ocoooooooooooooocooooooooooooo 



\ON«lOMCNl^«OINwNNfONHHMXfOOOOOO^fOIOHO\ff) 
000*0 NfONtON t^X vO t^ r^ r^ t^ t>.vO o x -^-oo iOX 00 VO cOX 00 t^vO 



o o o o o 






oooooooooo 



oooooooooooo 
oo ioo r^. r — i— 



c c o c o o o 



ocoooooooooooooooooooooooooooc 



rt-tOH h iom ION O O fOi- cOX NMOm cjm Q\ ro m m O tJ-vO »OX O 

M CON N M I-I NMNNMMHflMtOHMMMHMH I— I »— I t— t 



t^ CM 

6 M 



00 lONTi- 



cO CO rOO 00 O 1C00 OOOX t^ to -^-oc cOX O O 00 't >C 



on t». O r~» i-i *-> 

CO On tO iC tN CO 



OiOO^OOO^c 



On to XX cor^ON.C 
Oi-iOO-^-OtNOOOJvOi-iOC 



ON lO i-i tN (N lO 

tO m 0\m Q\N 



CO CM -^-00 VO 00 vO ON00 vO O00 lO CM ON O IOCN O'tNNlOfOH tJ"X cm »o 
<t lO lO CO ID fO lO Tj- m 10*0 CM Tt-^<NO t^cOCS CM I^h CM CM i-i i-i fOO CM 



CO iOiOmO N 
i-i O w N fO m 



o o o o o 



ION O 

i-i ^-vO 



o 




rfvO 




t^O vo 


C 


o 


tO o 


c 


to 


O vO 


M 


"*■ CO o 


lO CM 

o o 




l^C 


c 


c 


tO On CM 


rj-vo 00 vO 00 


^ 


r^ 


z 


On CO O 
i-i CM 


n 


CO 00. 


t^t>.00 


»o CO CO CO CO o 


M 


N 


t>. lO 


C 


o o 


O O 


O 


O 





O 


o 





o o 


o 


o 








o 


o 


o o 


o o 


o o 


o 


o 


o 






O O iovO OiOOioOiONOOMOOaiOiOOON iOM3 Cm On t^ On O O O 
CO tJ- t>» CM 00 -^"00 ^-m m m ^ OnvO IO00 O i-i O ^j- tOX 00 OX m Tj-oo X CO 
•*t-\T} i-i^CM^CNCOCMCOIO tOCO lOCMCMCMi-i <■* CO Tf rt" 



be be 

be c c 

.5 > > 

two >> Jy qj 

c & en w 



bfl 



CD 



•.52.2 CO ofl en ojo 

' XX) ox) C be C 

: «u cu.S'>.S'> 
:r23 £ « £ « 

, » m j) "i oj ") 
, — CD <fl CD m CD 

rt £?§> 2 £ £ 

c/n,-1 fcHfee- 1 



w j= &•$•< 



N N > 

" — ' =■ in en °f- oj 

o> rt.S-, cu-£ w 
•2 § & §oJ5 S^i o 

OcucucucucucL — 

^ccpccccd 

HOOOOOOE 






vj; <u 



be c 

o . 2.2 



T3 13 



tu 



eu 



*n 


. i- 




<u 


s 


c 




' rt 


T3 




U 


• a 






O 


c 


E 


o 




C3 










c 


cd 


q 


M 


crt 


be 


,Q 


« c 


« 


a; O 




SJ 


o 


rt 


- 


C/3 



. £ o be 
* a * 

' 23 Z 

. t-TJ - 
O 0) C 

a > o 
cu "ri 

111 

C - +-> <u 

•J rt o b 



tf be 
2 ps 



03 rt 

cu oj 
J2 _c <U 

£ " 5 

b ^ c 

o 3 "5 

is * 

Ji 2 cn- 
w rt C 
Jan! 
i- en cu 



O 

^ be 

oj be oj gj 

J^ rt > be 

O u "Z> d 

O <U ™ u 

> a3^3 > 



.2 S « cs 

•■ r! o r- c 

,2 o t- >- -m cu 
■p ao 3 u v 
»- q. a. o o 

o «-. .^3^ » 8 
_bJ0ajbeo^j3 ro -= . 
£.S:5-5:5 IT'S fe-2 "S 

rtrtcDrtajJ2^3^u 

CDCDCDCDCDrtrtrtCDO 

m PQ PQ CQ CQ U U U U U 



T3 --T3 

■o d 5 n 

CD J4.2 j*s 
c o -m o 

C P }h O 



CD 

be cd 
rt be 

> CD 

rt > 

- a 

c - 
o c 

'+3.2 • 

o t! 

a o . 

CD & 
• _ CD J^ 

en O 

i-JO 

ci3 cr7 



CD rt 

^CD 

OJ 2 > 

be cd rt 
«J > - 



• rj u cd 

o ^r2 
aa'Jj 

«U en <U-o 

•t; rt - CD 

" O 



J3 

CD O - - 
o u en en 

4-> en # _0 

aij c c 

M^OO 



a^. . 

CD O X3 
*— O CD 

r2 u J^ 

T3 - rt 
« CO 

^ Si Efi 

"S 2 

en en rt 

i-i rt -*- 1 
rt CD o 

Oh Oh Oh 



•a 

JS 

. o 

^ 8 

4 !•§ I 

W W (fl w 
CD CD CD CD 

o o o o 



T]*d o 

a ^ a 

3^JB 
x a .-2 

CD - 



en 



O O O O 
PUChCmCh 



a cd 



C en n 
O, en^ 

3 rt J- 
CmP^O< 



A VERAGE CHEMICAL COMPOSITION OF FOODS 673 



c o c c 



ooocoooccc 



o o o o c c 



OOmio r^x 

o> o> o> Cn onx 



o o c c c c 



Os G\ C\ Q\ Q\ t^ 



c o c c c c 



O C ©NO t^ rj- 

*H M< 



lOOOCCOOOOCO 



o o o 



o o 



o o 

ICO 



10OOOOOOOO 



o o o o c c 

co W CN iCfOt^ 



o o o o c o 
<o m x o ic -on 



i^OONn O 



fOOfOOOO 



WO c c 
o co r^x 



-* -* On O tJ-O 



O co iOO C iO 



•*r C O WX ic 

^ _; - _' o 6 



v© co X X t^Cl NIT, C ©n t}- 
O mh t^ © WX iO CO On co CN 



v© X 
6 d 



o w 

d 



•O ©nv© On i- m< 
co <N CO co iO co 



m CM COO ©v© co 
O X vO X iO iOO 



CN C) v© 



lOX Tj- CO 



O MX 



O N rC iC lOX 



Tf N« N IT, (\j O 

Tht^.r^.'-x ox r^t^r^o 


lO 

O Th ©\ O 


oac tCO - C O hC h 


0) ON "3- CO 


»OOOOOiOOCOOO 


c c c c 



co On ©nv© io ©s 



W co lO rh ro io 



C O C C O O 

l^ i- C co co "*■ 

mh CM i- t}- rf CM 



o o o o c 



©mo o c 

lO lO ^o 

CM mh CO 



o o c c o o 



VO MX M c O 
O M ^O f; C N 
^ _ HH _, _ 



3°S 



O n 

3 «j 

C . 



X (U X X 



a s x 3 =jc 



- 


x 

X 


r. 




"j 


CJ 








- 
















- 
















_ 
















c 


be 


H 


c 


r 


H 


r 


3 


— 





















- 














.3.3 




J3 


j= 


JzJ~ 


1) 


>> 




3 




3 


3 


3 


R) 




— 


~ 


~ 


— 


— 


— 


— 


3 


RJ 


- 


G 




- 


C 


c 


c 





c S rj L rs 

oc 



'•O o a; 3 U D 5) 
• c c o d C C 



• = E £ 
C x r- 



<y 0) 

b£ b£ 
3 tx 3 



i- <u i_ 



gj X 

eg 
o^o 
£ 2 






0£ 

RJ O 

' Jr. M ' ' 
Si £ 

"O ^ sj 

_ w « - ' bJ 

"0 tX x -c r* 

<u «J 3 a; 5 

3 g-s a '£ 

=•§ § ^ '-2 

2 - - x £ 

o o - «u a 

-o c, c js c 

^ "j C "*> C — 

-g 3 I « § 3 



U, 4> X 

^ x-c ya 
S3 fc = H 



."O rt »3 

-i_c rt S |S « u x 

m m .» _"13 C - 
^33^3^^^ 



Cm-O 
X o 
RJ 3 
- 0) 

3 £ 



+J X -— 



X 



•« RJ 

w 3j: 
.- 3 x a u _ 



— I X - 



LfljJdOO m 

3 2 P 2 S'S 

i"^ 5* 3 O 5 3 

43 



3- S <U^ 



o u - 

O X 3 

a) C ft t) " 

1-SaM 

O U 3-^^ 3 



x 

, SO U g^'fe 

U.U.OJCJOOiiOr-Cd O^^ - 

a)a;xxxxxxs3 « « JJ ^«>. 

+j +-> o i>o cj y a S 3 -- h — — S 

3 3-3^3-3_3-3J= U.Q23 U 22r 



Q 

a 

M 

O 

o 2f o bx CJ 

2 g 2 «> s ^ 

rt -~ * I e * 

■sss -I'S § 

^ 3.2 3 ^ X ,7 

rt"?t.2S2 fe 

mm u O T 1 ClTj 
^0l a S?S " 

x Q ^3 ~ -3 
3 ,r^0£ <U 

O H X w 0) 3 

a'S m«"S 2 

a a rt.bf> S 3 



4J CJ 

> b£ 
3 3 



3 lJr3 G3= 



rt 



<y <u ^ 2 

3 ^ C vw 

2 ? " U ^C 

. " * 1 i 2 S 

X X o O r^ — 

^ o. - n *c 2 u 



674 FOOD VALUE, WEIGHTS AND MEASURES 






<D a.e a 



Cs-. ro 
._■-' t-> 
CU o 

a-S " 
"ojs 6 

111 

O U -u 

§"° 2 

co d a 



4J O.S 

rt 8 fe 



r 



cd C 
J5 O 

o a 



aS 



-.a 

15 2 

co a 



S"rt 






ooooooocooooooooooooo 



oooooooo 



o o 

OVOO 



o o o o 

O CM to rj- 



o o 



o o o 

r^O rh 



o o 

ICO 



o o o o o o o 

^j- coO >OrO>ON 



o o o o 

ON Tj- CM O 



• o 



o o o o o o 

^1-TtOoo O O 



ONONMOaOMlONNOtOOtOOOi-PlO 

HOM^O^NMNfOMXNNOO^NOON^N 
NPImmPImmNmN m COM m tN m « h P( 



Ov CM vO < ^- 

d W m 6 



io • r^ cm 



oo vO rt- 



m d 



VO CM 



O O II O « HH 



00 IO co 

OOh 



■O C\-^ f^vo io 

• HI O CM l-l CM 1-H 



idtj-oo ^l-r^Thr^Tj-t^io^- o->vo O -^-iooo ioo o t>» 



ooooooooooooooooooooo 

IO00 cOr)-OvO lOO tCNNOoo OO cOO O 00 O O 
^O N ^-Pl m r»jM n m ^to r^oo Ov CO t^. CM tJ- r^o O 
mmOmMmNmMm nmNmmNmhNN 



c-S. 





s 
■> 

0) 
CO 

c 








co 
bo 1 



. CO 

, cu 

, # > 

' ° bo h to «S 
• c u, eg o3 cu 

: £ >^ *& 

. « £ boo jn E? 

-" > CU «u gjS 

§■« £?£:3 <u 

_Q 3 cd-C £ 3 

<OJHOO 



o o 



' cu 
bo 
o o3 
bo >h 
cd £ a 

_ cu > 
C co aj 

o 2 * 

•- .3 -o 

a n * 

a ax 

_^ to jJ 

a 



cu "O CO -^ CU Vl 

a ^.jy, m .ti.y cu 



cu 3 cu 

> # u O- cu 



~'C n3 



;g»«.s"c 



cu cu 

CU CU 

3 3 



^.fU CU COv£ -r- 

o3 £X> cu cu cu g 

+-> i- a a. o, a, s 

3 cu cd 03 03 03 3 



PQfflUUOOOOiJEOO 



co co co 
cu cu cu 
bOjr ,3 
3 cu cu 
03 03 03 
J- cu cu 



OOOOOOOO 



CM CO lOO CM IO CM CO 

N N N IOM ^m fO 



OOOOOOOO 

r^o t^o oso c o 



NOiOO-tMOO 



cm Tfr^.i^i-icx)'cOTi- 

CMCMCMr^CM-^-»-icO 



MCiOH cOt^cO'^t 

M M M lOM M P| 



XvO OOMO IO CM 
On Ovoo CM "^-00 Ovoo 



OOOtI-cmOOO 



OOOOiOOOO 



cu cu 

o o 

cu cu ' 

'a'a 

cu cu 

'- - 

03 03 

3 3 

o- cr 

co co 



3 SS^3 

"O'o'-f; c?-i=-o 

Ui In ft 3 JJ • 

O = g 4p o3 

^^"rt^ Oi3 
03 03 g C ^ 03 

£Kc/)OH£ 



cu cu 

bf bO 

k3 a3 

CU CU 

W CO 

2 n3 



5 3 



Js CU _^ 

^3 £J rt * 

°i co" co" S c " 
tn cu cu •- O 

area H-oJ 

E 



0) 



cd 3 2 2 2 13 

cy .3 o3 o3 r\ y^z 



-o 

cu 
co 
cd "O 

JS cu 
cu co 

u a 

en 3 2 • -"° &"^ 

o3 o crj cu 2 cu 

»43 co fd X 

uT co cu . . co -3 o3 

^^3 -sy-s 

JS-P cuz^'S cti - 03 

° 3 O 3 bfl£ 

JS .3 cu. T— T - C O 
U bO w ^ ^.3^2 

cu cu cu .2 iS &B >, g 

O3o3o3330o3^ 



A VERAGE CHEMICAL COMPOSITION OF FOODS 675 



oooooooooooo 



o o 
c o 



ooooooooooo 

Ox rt-M o\Q t^^o n n n 



oooooooooooo 



o o 

3" M 
30 ON 



ooooooooooo 



oooooooooooo 

lO »o On^O X 'O nO t^X M i-i i-i 



io io o o 

O O -h <N 



OOOOOOOOOOO 
rOfOOvO <t O On On 6 NO O 



vO tO 3" 3" fO 0) ro 



C*3 O lOlOO 
3" 3" 3" rsj N rj- 



O On O 10^-000 IO 3" lOX 
N m h O i-NH H TtM H 



r^ 3- 3-x <ono oo 

CO cO ro ro 3" 3" O 



n-vo o 3- 



o • o o 
6 : o\o 



(N| lOf^lCO M M NO O H 

X X ONX X 01 OVX X O On 



i-« m ?r> ?r> o 3- o 
»h m m i-* m n n 



O O N »o 



- MM N N 

c o o o o 



- fOfOO^M tJ-i-1 O\OO0 IO 
f^fOM CO On O) m c< tJ-p-i 0) 



rON N N N rn 



rO <N On t^ 00 NN 
ir> io 3" io to 3" 3- 3"0 


nO X 
3" 3" 


OOOOO^OOO 


O o 


oxooooooo 


o o 


io -t -i- <tvo O 3-cOX 

W •-• « •-! H-rJ-M M M 


CO 3- 



OOOOOOOvOOvOOO 



X O lOX IO lOX nO lO^sO ONX 
CO CO IO CO CO IO X iC N (O N O 



O fO o o o o 



D O j) jj O 5; 



0) ^OJ 1) q_0) 

u 03 ■_ u ~ u 
03 C 3 05 C 3 

Oj- O Oj. o 

-a t^-o v~o 



x > x _C 

U. t/5 V- r- *- 

• X. 3 • X U K^ 



5111 
g.S'E'S 

o<*- o o 



u2"5'5^2 ° 



o__ 



SS^ 3 



oj D n ai <u u 
c c c c c c 
OOOCOO 



3 a3 «» 6 12 o 

I > X en O fe 



a; _, 3 3 

y y 

3 C <U"0 ^ ^ 

y y qj c i- s- 

en en H 



o o 



§ s 

-O J2 

< r- 



X> 

s «'« 

-£3 3 
.3 O O 

-3XX 



* j= S 2 * 

03 -*-" 05 03 i~ 

*■" 3 >- >- 3 

3 a 2 3 a « 

a^ a a ^ 



^ ■*-» 3 

o +j a> a; 

ojxi-j: e 

e c c - 



si 






a; > c o3 a; 



Si c « 

a c 3 



d o a) 4) a; d 



* ■ * - S E £ a 

s*s &.S.2.S.S.S x 

= •■« "o -o -a -a T3 .2 

T3"o-o-o a 

3 3 3 3 3 3 



bfi • 

3 

u 

> 

3 

- <y 
C bX) 
O 3 



3 C 

4J O 



— -O 






a 



g; w 5 

x "O » 

3 3 x 

-■^: a> 

^ 3 x 
>> 3 x 

c £-5 

5 oj o 



1) oj C 



X X 



lOuCL.ft.ft.CUCLOL.OHCUCUPLHE-' S. 



OOcn 



3 3 



t- a 

3 3 
OiO •« 
3 >» 

enen 



^ 3 

o-^ 

3 (U 
— OJ 



3 3 
3 3 

r3 a> 

n -*-> 

2 3 

ca oq 



^ 3 

•3.2 

*-o ti 

• <y o 
. x a> 

£!3 

*9)D 

~ 3 en 



3 c -M Vm -M en 



©io 3 t: 

3.2 o 
> o 5J 

. OX cu 



3 ^- 
o x 0? 

y OJ X) 
0.3 32 
O U U, 



O 3 3 = 
^ 3 o5^ 
O 3 u o3 



676 FOOD VALUE, WEIGHTS AND MEASURES 



Us 



<u D <j 
2 "S o 

&-S2 




u o o 

S c3 o 
g«3 

S-o o 




Actual a 
fat, an 
each P 
ories- 


c 
"5 
o 



-u o 



ooooooooooo c »c c o o 



c o 



o o o o o 



Tf- NHlOMlONHlOO'^HMNNOO 100 

oo r^oo oo r^vo oor^r^ONooONococoooooo oo n 



OOOOOOOOOOOOOOOO 



o o 



o oooooooooooooooo 

ON NfOOONHM'txaOQONfON^iC 



o 

01 ON 



Ol lO 01 CO00 00 fDtOO O Ol NNlOfOlOO 

d r^ o o no »o hh 

01 "-i oi CM hh hi CM 



O hhOO<NCNOhhOOOOOOOOO 



CO co 
O M 



co O THOfONO CO <^t- Ol tj-OnOniO^nO rj- 
Ol cOrONMOlNfO'^-NOtMNrOfOWM 



ON Ol 
CM CM 



h4 MHQOO't^iOOrOO 



ON 00 

d d 



o oooooooooooooooo 
ro oooor^cocooo onoo t^ j^ io r^oo t^ t^ 

Tt" COcOCM010101i-il/"S0100 01c001CMCMCM 



oooooooo 

NO CM HH 00 



O O CO Tt- 
^ On CO lO 



oi • O iom o -oo 
r^. • On hi cm lO • m 



on o cm r>»oo t^ r^ hh 



CM NO O CO UONO ONOO 
hh 01 



OOOOOOOO 

OOhNOOOOO 
IT500 01 00 lOOO CO CO 

_, cr, _ M 00 01 



o " 



|.s 






« a, 
C5 O. 






oi3 



o C 

2 c. 



o a> 



"3 >. 



CU-- 

» S3 

l'l 



biO to 
co co b/D > 15 

»H I- C "- 1 _C 

cu <v •- oj -^ 

-SiS b - '* 

HhJOO 



ojo^ 

> CU~ 

1/1 u h .- 



oooc 



<" 5 

QiO ft 
cfl 

a; .. 

-rt ^ 
"-* 

co a 
a o 

to o 



£ft£ 

d a CO 
u ^ 

nj -— r 

3 £ <* 



M 



-o-o 

03 05 

cy a) 

raw 



5 T2 £ 03 b/0 

O 3 5 «J t3 03 

-C C f5 £ CU >- 

- r 5 -5 £ -2 £ 

a) b" f° "ti o h* 

| " & g g * 

cu -C — - .. w • — 
ojO fe 03 co co ► C 

cu-O C^^.S ^ 



O 

_- 

cu 
bfi 

03 -V 
u, cu 
^J^ 
S o 

03 n 






03 

C bX) 
03 03 



co > 

cu o - 

> <u o ii 

M CU 1- !> 

03 > CU > 

3J 03 C 

b x; cu 



CjC 



c 



It 



"O co 
cu cu 

^ J* 

O 

<U CU£J CU 



o 
>. 
o 



a 

cu $ 
biO-M 

cu > 



cu 

ft 

O 



o 
bfl 

rt +i rt ti cu 

i_ C H 2 T3 

cu cu b/) ft S 

03 »5 ^ ^T be 

• -3 O O O ^ ^ 

CU .|_) 4_) ^_i •— CO 

-5, 03 03 03 2 -Q 

OX) CU cu CU , , 7! 

03 js JS J2 



N 



. . 03 

-a" 

cu 

o5 «» O- 
co - 



CO 



CO 



^ CU £j i > 



s- I 



- - - ^ - £ 

^co _co __co ^ c c 

"c "(C "c "flJ 03 cu 

CU CU CU CU CU J-, 

J3 j=;xl-Q^ o 



ft ^_ 

co vT 

03_CU 

cu ^ 

u 



%%** 



cotnmaaasc 

bJ0bi0biO333 c 5 
biObJDbiOo O O °-- 



VALUE OF FOOD IN SMALL QUANTITIES 677 



Table Showing the Nutritive Value of the Food Materials Calculated 
for the Quantities Commonly Required in Cooking Small Portions. 1 



Food material 


Measure. 


Weight. 


Protein. 
Gms 


Fat. 
Gms. 


Carbo- 
hydrates 


Fuel 

value. 


(uncooked). 


Oz. 


Gms. 


Gms. 


Calories. 


A 
Almonds shelled . 


i cup 


S% 


160.0 


33-6 


87.8 


27.7 


10350 


Apples, fresh . 


i medium 


5 + 


150.0 


0.5 


05 


16.0 


70.0 


Apples, dried . 


i cup 


3 


85.0 


1.4 


1.8 


56.2 


247.0 


Apricots, dried 


i cup 


5 


142.0 


6.6 


1.4 


88.5 


354 


Arrowroot .... 


i tbsp. 


% 


14+ 






13.8 


55-0 


Asparagus .... 


i bunch 


44 (2K 


1247.0 


22.4 


2.4 


41.0 


276.0 


B 




lbs.) 












Bacon 


i serving 


s 


18.0 


1.6 


10.4 




100. 


Bacon 


i lb. 


16 


454 -o 


43-0 


269.4 




2597.0 


Bananas . . . 


i medium 


3K 


100. 


0.8 


0.4 


14.0 


64.0 


Barley, pearl 


i tbsp 


I 


27.0 


2.2 


0.3 


19.8 


90.0 


Barley, crushed 


i tbsp. 


y, 


14+ 


1 . 1 


0. 1 


n. 3 


51.0 


Barley, flour . 


i tbsp. 


yi+ 


16.0 


1.3 


0.2 


12.5 


57.0 


Barley, flour . 


i cup 


8 


227.0 


19.0 


2.5 


174-3 


796.0 


Bass (edible portion) . 


i serving 


3M 


100. 


18.6 


2.8 




100. 


Bass (edible portion) . 


i lb. 


16 


454 .0 


84-3 


12.6 




452.0 


Bean flour .... 


i tbsp. 


10 


8.0 


1.8 


0. 1 


'4-8 


28.0 


Bean flour .... 


i cup 


4s 


125.0 


29 -3 


2.3 


77-5 


448.0 


Beans string . 


i serving 


4 


1130 


2.4 


0.3 


5-8 


44.0 


Beef broth . . . 


i serving 


3K 


100. 


1.8 


1.02 




16.5 


Beef broth . . . 


i quart 


32 


907.0 


16.5 


9-3 






149.0 


Beef juice .... 


i serving 


3K 


100. 


4-9 


0.6 






25 


Beef marrow . 


i tbsp. 


X 


14. 1 


0.31 


13. 1 






120.0 


Beef marrow 


i lb. 


16 


454-0 


9.92 


420.8 






3828.O 


Beefsteak porterhouse 


i serving 


3M 


100. 


19. 1 


18.0 






238.O 


Beefsteak, porterhouse 


i lb. 


16 


454 .0 


86.6 


81.2 






1077.0 


Beefsteak, rump . 


i serving 


3K 


100. 


21.0 


13.7 






207.0 


Beefsteak rump . 


i lb. 


16 


454 


94-8 


62. 1 






938.0 


Beefsteak, sirloin . 


i serving 


3H 


100. 


16.5 


16. 1 






211. O 


Beefsteak, sirloin . 


i lb 


16 


454 


74-8 


73-0 






957.0 


Beefsteak, top of round 


i serving 


3K 


100. 


19-5 


73 






I44.O 


Beefsteak, top of round 


i lb. 


16 


454 .0 


88.45 


33- 1 






652.O 


Blue fish, edible portion 


i serving 


3M 


100. 


19.4 


I . 2 






88.0. 


Blue fish, edible portion 


i lb. 


16 


454 .0 


87.8 


5-44 






401 .0 


Brandy .... 


i tbsp. 


J<£ 


14 + 










42.0 


Bran 


i cup 


2)4 


71 .0 


'i'.& 


1.5 


43-4 


218.0 


Brazil nuts, shelled . 


i lb.. 


16 


454 


76.94 


302.88 


3168 


3048.0 


Brazil nuts, shelled . 


i nut 


% 




1.2 


4-74 


0.05 


47.6 


Brazil nuts shelled . 


i tbsp. 
chopped 


H 




3.6 


14.22 


0.15 


142.8 


Bread, white . 


i slice 


i 


28.4 


2.6 


0.3 


150 


73 .0 


Bread, white . 


i loaf 


12 


340.0 


31.6 


4.1 


179.3 


881.0 


Bread crumbs (dry) . 


i cup 


4i 


136.0 


12.6 


1.6 


71-7 


352.0 


Bread, Boston brown 


i small 
slice 


i 


28.4 


1.5 


0.5 


13.3 


64.0 


Bread, gum g.uten 


i slice 


i 


28.4 


8.4 


0.3 


8.5 


70.3 


Bread, gum gluten 


i loat 


13 


386.5 


114. 


4.0 


116. 3 


957-2 


Butter 


i tbsp. 


M 


14 + 


0. 1 


12. 1 




109.0 


Butter 

C 


i cup 


8 


227.0 


2.2 


193 




1744.0 


Carrots .... 


i small 


2 


57-0 


0.5 




4.2 


20.0 


Cauliflower 


i serving 


4 


1130 


2.0 


0.0 


5-2 


35.0 


Celery 


i serving 


2 


57.0 






1.4 


6.0 


Cheese, American 


i tbsp. 


K 


150 


4.0 


50 




62.0 



1 A. F. Pattee: Practical Dietetics, p. 64, 10th edition. Reproduced by special permission. 

The weights assigned to the various measurements in this table have been determined care- 
fully, but are the results of a limited number of experiments, and hence must be regarded as only 
approximate. The food values are given with sufficient accuracy to be within the limits of error of 
computations made on average analysis of food-stuffs. 



678 FOOD VALUE, WEIGHTS AND MEASURES 







Weigh t- 






Carbo- 


Fuel 


Food material 


Measure. 






Protein. 
Gms. 


Fat. 
Gms. 


hydrates 
Gms. 


value. 


(uncooked). 


Oz. 


Gms. 


Calories. 


Cheese, American (fres 


h 














grated) . 


2 tbsp. 


1 


28.4 


8.0 


10. 




124.0 


Cheese, cottage 


1 serving 


1 


28.0 


5-9 


0.28 


1.2 


310 


Cheese, creamed . 


2 tbsp. 
(iH cu. 
inch) 


8 


23 


6.1 


8.1 


0.5 


100. 


Chicken, edible portioi 


1 1 serving 


3K 


100. 


21.4 


2.5 




108.0 


Chicken 


1 lb. 


16 


454 .0 


97-5 


11. 3 




492.0 


Chocolate, unsweetene 


d 1 square 


1 


28.4 


3.65 


13.8 


8^59 


173-0 


Chocolate, unsweetene 


d 1 lb. 


16 


454-0 


58.5 


220.9 


137-4 


2772.0 


Clams, edible portion 


1 serving 


3% 


100. 


8.6 


1.0 


2.0 


5i-0 


Clam bouillon 


1 serving 


z'A 


100. 


0.2 




0.2 


2.0 


Clam bouillon 


1 quart 


32 


906.0 


2.0 


0.8 


1.6 


23 


Claret (10 per cent, al 
















cohol) ... 


1 tbsp. 


y* 


14.0 








10. 


Cocoa . 


1 tbsp. 


yi 


7 + 


15 


2.0 


2.5 


35-0 


Cod, fresh (edible por 
















tion) .... 


1 serving 


3K • 


100. 


16.5 


0.4 




70.0 


Cod, fresh . 


1 lb. 


16 


454 .0 


74-8 


1.8 




3i5.o 


Cod fish, salt, boneles 


5 1 serving 


2 


57.o 


15-7 


0.2 




64.0 


Cod fish, salt, boneles 


; 1 lb. 


16 


454 .0 


125.6 


1-4 




5150 


Condensed milk . 


1 teaspoon 


0.388 


11 .0 


0.88 


1.057 


6.07 


3731 


Condensed milk 




I 


28.35 


2.27 


2.72 


15-66 


96.2 


Condensed milk 


1 can 


16 


450.0 


36.33 


43-79 


250.6 


1541-8 


Consomme 


1 serving 


3% 


100. 


2.5 




0.4 


12.0 


Consomme 




1 quart 


32 


906.0 


10. 




1.6 


46.0 


Corn 




1 cup 


10 


28.4 


7-9 


3-4 


539 


278.0 


Cornmeal . 




1 tbsp. 


% 


10. 


0.8 


0.2 


7-1 


330 


Cornmeal . 




1 cup 


5 


142.0 


130 


2.6 


106.8 


504.0 


Cornstarch 




1 tbsp. 


% 


10. 






9-5 


38.0 


Cornstarch 




1 cup 


5K 


156.0 






148.2 


592.0 


Cracker crumbs . 


1 cup 


5 + 


1510 


16. S 


9.0 


no. 2 


588.0 


Crackers, water 


1 large 


% 


10. 


1 .2 


0.5 


7-6 


40.0 


Cream, thin (18%) 


1 tbsp. 


% 


14.0 


0.4 


2.8 


0.7 


29.0 


Cream, thin (18%) 


1 cup 


8 


227.0 


5.6 


41.9 


10.2 


440.0 


Cream, thick (40%) 


1 tbsp. 


% 


14.0 


0.3 


6.0 


05 


57-0 


Cream, thick (40%) 


1 cup 


8 


227.0 


4-99 


90.7 


6.8 


864.0 


Cucumbers, fresh (edi 
















ble portion) 




1 


28.4 


23.O 


0.06 


0.89 


5-0 


Currants, fresh 


1 cup 


5 


142 . 


2. 12 




18.0 


81.0 


Currants, dried 

D 
Dates .... 


1 cup 


8 


227.0 


5.44 


'3-84 


84.0 


728.0 


1 cup, with 


8 


227.0 


4.0 


5-6 


160.8 


710.0 




stones 














Dry peptonoids, solub 

E 
Eggs, whole averag 


le 1 tbsp. 


2 


159-0 


6.0 




8.0 


57-0 
















size (without shell) 


1 


iK 


45 .0 


5-4 


4.2 




60.0 


Eggs, white 


1 


9 


25.0 


3-3 






13-0 


Eggs, yolk . 
F 
Farina .... 


1 


M 


130 


2. I 


4-5 




48.0 


1 tbsp. 


% 


10. 


1.0 


0. 1 


7.2 


34-0 


Farina .... 


1 cup 


6 


170.0 


18.7 


2.3 


129.8 


616.0 


Figs 


1 fig 


1 


28.4 


1-3 


0. 1 


22 .2 


95-0 


Figs .... 


. M lb. 


8 


227.0 


9-7 


0.7 


168.2 


718.0 


Filberts, shelled 


1 lb. 


16 


454 


70.72 


296. 16 


58.88 


3184-0 


Filberts, shelled 


1 doz. 


l A 




3-3 


13 .89 


2.76 


150.0 


Filberts, shelled 


1 tbsp. 
(chopped) 


% 




2.21 


9.26 


1.84 


100. 


Flour, barley . 


1 tbsp. 


K + 


16.0 


1.3 


0.2 


12.5 


570 


Flour, barley . 


1 cup 


8 


227.0 


19.0 


2.5 


174-3 


796.0 


Flour, gum gluten 


1 tbsp. 


% 


8.0 


3.46 


0. 12 


3.48 


29.0 


Flour, gum gluten 


1 cup 


5 


142.0 


60.O 


2.3 


63.0 


512.7 


Flour, Graham 


1 tbsp. 


% 


8.0 


1-3 


0.2 


6.8 


34-0 


Flour, Graham 


1 cup 


5 


142.0 


18.8 


3-2 


101 .2 


5090 


Flour, rice . 


1 tbsp. 


% 


1 16.0 


1-4 


0.04 


10.2 


58.0 


Flour, rice . 


1 cup 


8K 


241.0 


18.9 


0.7 


187.8 


870.0 


Flour, rye . 


1 tbsp. 


H 


8.0 


0.5 


0.07 


6.3 


28.0 


Flour, rye . 


1 cup 


5 


142.0 


9.6 


1-3 


in. 5 


496.0 


Flour, wheat (rolle 


r 


l A 












process) . 


1 tbsp. 




8.0 


0.9 


0.08 


6.0 


28.0 


Flour, wheat (rolle 


r 














process) . 


1 cup 


5 


142.0 


15-9 


1-4 


106.2 


500.0 


Fowl (edible portion) 


1 serving 


3M 


100. 


193 


16.3 




224.0 


Fowl (edible portion) 


1 lb. 


16 


454 


87.5 


73-9 




10150 



VALUE OF FOOD IN SMALL QUANTITIES 679 







Weigh*" 






Carbo- 


Fuel 


Food materia] 


Measure. 






Protein. 
Gms. 


Fat. 
Gms. 


hydrates 
Gms. 


value. 


(uncooked). 


Oz. 


Gms. 


Calories. 


G 

Gelatin, granulated 


i tbsp. 


3 

15 


8.5 


7-8 






310 


Gelatin, granulated 


i box 


iV 


34-0 


31.1 










125.0 


Gelatin, shredded 


K box 


5 


17-0 


15.6 










62,0 


Gum gluten flour . 


i tbsp. 


% 


8.0 


3-46 





12 


3 


48 


29.0 


Gum gluten flour . 


i cup 


5 


142.0 


60.0 


2 


3 


63 





512.7 


Gum gluten flour . 


i lb. 


16 


450.0 


191. 


7 


3 


2C0 





1629.7 


Gum gluten bread 


i slice 


i 


28.4 


8.4 





3 


8 


5 


70.3 


Gum gluten bread 


i loaf 


13 


386.5 


114. 


4 





116 


3 


957-2 


Gum gluten biscuit 


i biscuit 


X 


7.0 


2.94 





13 


3 


15 


25-5 


Gum gluten noodles 


i cup 


3K 


100. 


45 -o 


4 


2 


32 


5 


350.o 


Greens .... 


i serving 


4 


113.0 


2.3 





3 


3 


6 


27.0 


Grapes, Malaga 


i doz. 


2 


57.0 


0.74 





9 


10 


88 


55 


Grapes, Malaga 


i lb. 


16 


454 .0 


4-5 


5 


4 


65 


3 


328.0 


Grape juice 


i tbsp. 


i/ 


14.0 








3 


8 


150 


Grape juice 

H 
Haddock, edible portic 


i cup 


8 " 


227.0 






60.O 


240.0 


>n i serving 


3 X A 


100. 


172 


0.3 




72.0 


Haddock, edible portk 


>n i lb. 


16 


454 -o 


77-9 


1.36 




324.0 


Halibut, edible portioi 


i i serving 


3K 


100. 


18.6 


5-2 




121 .0 


Halibut, edible portioi 


i i lb. 


16 


454 


84.3 


23.5 




549 -o 


Ham, fresh, lean . 


i serving 


3 l A 


100. 


24.8 


14.2 




227.0 


Ham, fresh, lean . 


i lb. 


16 


454-0 


112. 6 


64.4 




1029.0 


Hickory nuts, shelled 


i lb. 


16 


454 


6976 


305.6 


5^68 


32340 


Hickory nuts, shelled 


X cup 
(chopped) 


iK 




6.54 


-28.5 


4-8 3 


303-0 


Hickory nuts, shelled 


i tbsp. 
(chopped) 


K 




2.18 


9-5 


1. 61 


101 .0 


Hominy 


i tbsp. 


K 


14.0 


1 .2 


0. 1 


11 .2 


50.0 


Hominy 


i cup 


8 


227.0 


18.9 


1-4 


179.2 


8050 


Honey .... 

J 
Jell-O .... 


1 i tbsp. 


i 


28.35 


0.13 




230 


92.0 


i box 


2 Y 2 


100. 


11 .2 




86.4 


395-0 


Jell-O .... 

K 
Koumyss 

L 
Lamb chops . 


i serving 


5 


16.0 


1.9 




144 


66.0 


i qt. 


34s 


975.0 


2.2 


2. 1 


1.5 


328.0 


r serving 


3K 


100. 


18.7 


28.3 




3290 


Lamb chops . 


i lb. 


16 


454 .0 


84 


8 


128.3 






1494 


Lard .... 


i tbsp. 


K 


14.0 






14.0 






127 .0 


Lard .... 


. i lb. 


16 


454 .0 






484.0 






4083.0 


Lemon juice (i lemon 


) 3 tbsp. 


l% 


42.0 








4 


2 


17.0 


Lentil flour 


i tbsp. 


Iff 


0.0 


2 


3 


0.9 


5 


3 


310 


Lentil flour 


I cup 


5 


144.0 


37 





i-4 


85 





500.0 


Lettuce 


i head 


8 


227.0 


2 


3 


0.5 


5 


7 


36.0 


Liquid peptonoids 


i tbsp. 


K 


ISO 





8 




2 


1 


28.0 


Lobster, edible portio 


n i serving 


3H 


100. 


18 


1 


1 . 1 





5 


84.0 


Lobster, edible portio 

M 
Macaroni . 


n i lb. 


16 


454 .0 


82.08 


4.96 


2.24 


382.0 


i cup 


3f 


108.0 


14-7 


1 .0 


81. 1 


392.0 


Mackerel, fresh (edibl 


e 














portion) . 


i serving 


3K 


100. 


18.7 


7-1 




139-0 


Mackerel, fresh (edibl 


e 














portion) . 


. i lb. 


16 


454 


84.8 


32. 16 




629.0 


Mackerel, salted . 


i serving 


z x A 


100. 


16.3 


17.4 




222.0 


Mackerel, salted . 


. i lb. 


16 


454-0 


73-9 


78.9 




1007.0 


Malted milk, Horlick 


s i tbsp. 


K 


14.0 


23 


1.2 


9-5 


59-0 


Milk, whole 


i tbsp. 


15 


20.0 


O.06 


0.8 


1.0 


14.0 


Milk, whole 


i cup 


&i 


244.0 


8 





9 


-3 


12 


.2 


169.0 



680 FOOD VALUE, WEIGHTS AND MEASURES 







We 


ght. 






Carbo- 


Fuel 


Food materia 


1 Measure. 




Protein. 

Gms. 


Fat. 

Gms. 


hydrates 
Gms. 


value. 


(uncooked). 


Oz. 


Gms. 


Calories. 


Milk, whole 


i quart 


34 % 


9750 


32.2 


39.o 


48.8 


6750 


Milk, skimmed 


i tbsp. 


i 7 o 


20.0 


0.7 


0.06 


1 





70 


Milk, skimmed 


i cup 


8| 


244.O 


8.3 


0.7 


12 


5 


89.0 


Milk, skimmed 


i quart 


341 


975-0 


33.1 


2.9 


49 


7 


358.0 


Molasses . 


i tbsp. 


1 


27.0 


0.6 




18 


7 


77.o 


Molasses 


i cup 


ii 


317.0 


7-6 




219 


7 


909.0 


Mutton chops . 


i serving 


2,V* 


100. 


16.0 


33.1 






362.0 


Mutton chops . 

N 
Noodles, gluten 

O 
Oatmeal, granulat 


. . i lb. 


16 


454 


72.5 


150. 1 




1640.0 


i cup 


3K 


100. 


45-0 


4.2 


32.5 


434 


ed . i tbsp. 


y 2 


14.0 


1.8 


0.9 


99 


550 


Oatmeal, granulat 


ed . i cup 


% 


2270 


28.8 


14-7 


158.2 


880.0 


Oats, rolled 


i tbsp. 


5 


5.o 


0.7 


0.3 


2.7 


16.0 


Oats, rolled 


i cup 


2K 


71.0 


11. 8 


5-2 


46,9 


282.0 


Olive oil, Nicelle 


i tbsp. 


x 


15.0 




150 




1350 


Olives . 


. 2 or 3 


X 


14.0 


0. 1 


2.8 


1.2 


310 


Onion . 


i serving 


4 


113.0 


1.8 


0.3 


II. 2 


56.0 


Orange . 


i medium 


5 


142.0 


1.2 


0.3 


17.4 


77-0 


Orange juice . 


i tbsp. 


X 


14.0 






1.6 


6.0 


Orange juice . 


i cup 


8 


227.0 






25.6 


104.0 


Oysters 


2 


I 


28.4 


1.7 


0.3 


1.0 


14.0 


Oysters 


i cup • 


6 


170.0 


10. s 


2.0 


6-3 


84.0 


P 


(solid) 














Panopepton 


i tbsp. 


X 


150 


1.0 




2.5 


30.0 


Peaches, fresh . 


i medium 


4 


113. 


0.8 


0. 1 


II. 3 


50.0 


Peaches, dried 


i cup 


3 


85.0 


1.4 


1.8 


56.2 


2470 


Peach juice 


i tbsp. 


X 


14.0 






1. 1 


50 


Peach juice 


i cup 


8 


227.0 






17.6 


80.0 


Peanuts, shelled 


i cup 


5^ 


142.0 


36.55 


54-7 


34-55 


777.o 


Peanut butter 


i tbsp. 


15 


16.0 


4-8 


7-7 


2.8 


100. 


Peas, green 


i serving 


4 


113*0 


7-7 


o.S 


19.6 


114. 


Peas, canned . 


i cup 


6H 


184.0 


6.6 


0.4 


18.0 


100. 


Pea flour . 


i cup 


5 


144.0 


36.9 


1-5 


93-0 


533.0 


Pea flour 


i tbsp. 


IU 


9.0 


2.3 


1.0 


5.8 


330 


Pecans, shelled 


i cup 


SX 


156.0 


150 


110.0 


23.8 


11450 


Pineapple, fresh (e 


iible 














portion) . 




8 


227.0 


0.9 


0.7 


22.0 


98.0 


Pineapple, canned 


i slice 


3 


85.0 


0.4 


0.6 


31.0 


130.5 


Pineapple, canned 


i cup 


8 


227.0 


0.9 


1.6 


82.6 


348 • 


Pineapple, canned 


i can 


24 


680.0 


2.6 


4.8 


247.0 


1044.0 


Port wine (10 per c 


ent. 














alcohol) . 


i tbsp. 


X 


14.0 








10. 


Potatoes, white 


i medium 


ZX 


100. 


2.2 


0. 1 


18.4 


830 


Potatoes, sweet 


i medium 


ZX 


100.0 


1.8 


0.7 


27.4 


123.0 


Prunes . 


i cup 


5 


142.0 


2.5 




88.1 


3630 


Prunes . 

Q 
Quail . . . 

R 
Raisins 


3 prunes 


I 


28.4 


0.5 




17.6 


72.0 


i serving 


zX 


100. 


21.8 


8.0 




I590 


r doz. 




9.0 


0.2 


0.3 


6.5 


290 


Raisins 


i cup 


4/3 


113.0 


2.6 


3.4 


77-6 


352.0 


Raspberries, fr 


esh, 














black (edible por 


tion) i cup 


5 


142.0 


2.4 


1.4 


17.8 


94 


Raspberry juice 


i cup 


8 


2270 






22.6 


90.0 


Rhubarb 




I 


28.4 


0.2 


0.2 


1.0 


6.0 


Rhubarb 




16 


454 


2.7 


32 


16.3 


1050 


Rice . . . . 


i tbsp. 


X 


150 


1 . 1 


0.04 


11. 2 


50.0 


Rice . . . . 


i cup 


8K 


240.0 


18. 1 


0.7 


179. 1 


7950 


Rum . 


i tbsp. 


K 


14.0 








38.0 



VALUE OF FOOD IN SMALL QUANTITIES 681 







Weight. 






Carbo- 


Fuel 


Food material 


Measure. 






Protein. 
Gms. 


Fat. 
Gms. 


hydrates 
Gms. 


value. 


(uncooked). 


Oz. 


Gms. 


Calories. 


S 
Salmon, edible portion 


i serving 


3K 


100. 


22.0 


12.8 




203.0 


Salmon, edible portion 


lib. 


16 


454 -0 


99-6 


57- 


9 




922.0 


Saltines .... 


i wafer 


v% 


30 


0.4 


0. 


5 


2.4 


150 


Sardines, canned . 


i serving 


3K 


100. 


23.0 


19. 


7 




269.0 


Sardines, earned . 


i can 


16 


454 


104.3 


89. 


2 




1221 .0 


Shad (edible portion) 


i serving 


3K 


100. 


18.8 


9- 


5 




161. 


Shad (edible portion) 


i lb. 


16 


454 • 


85.1 


43- 







7290 


Shad roe .... 


i serving 


3K 


100. 


20.9 


3- 


8 


26.0 


128.0- 


Sherry 


i tbsp. 


y 


14.0 










130 


Spinach .... 


i serving 


4 y 


Vs 


2.3 


0. 


3 


'z-6 


27.0 


Squabs 


i serving 


zy 


100. 


16.3 


36. 


2 




3910 


Squash 


i serving 


zy 


100. 


1.4 


O. 


5 


90 


46.0 


Strawberries (ed. port.) 


i serving 


4 


113. 


1 .0 


O. 


7 


79 


42.0- 


Strawberries (ed. port.) 


i cup 


6 


170.0 


1.5 


I 





11. 9 


.63.0 


Strawberry juice . 


i cup 


8 


227.0 








II. 4 


450 


Suet 


i tbsp. 


y 


14.0 


'o.'66 


II 


59 




107.0 


Suet 


lib. 


16 


454-0 


21.28 


371 







34250 


Sugar, granulated 


i tbsp. 


K + 


150 








15.0 


60.0 


Sugar, granulated 


I cup 


7K 


210.0 








210.0 


840.0 


Sugar, loaf 


i lump 


s 


7-6 








7-6 


30.0 


Sugar, loaf 


I cup 


ty 


184.0 








184.O 


736 . 


Sugar, powdered . 


i tbsp. 


y 


12.0 








I2.0 


48.0 


Sugar, powdered . 


I cup 


6K 


184.0 








184.O 


736.0 


Sugar of milk . 






1.0 








100 0% 


4-1 


Sugar of milk . 


i teaspoon 
(av. size) 


o. 164 


50 








100.0% 


20.5 


Sugar of milk . 


i tbsp. 


0.564 


16.0 








100.0% 


65.6 


Sweetbreads . 


i serving 


3K 


100. 


16.' 8 


12 


1 




176.0 


Sweetbreads 


i lb. 


16 


454.0 


76.2 


54 


8 




798. 


Sweetbreads 


i pair 


8 


227.0 


38.1 


27 


4 




399 • O 


T 


(med. size) 














Tapioca, pearled . 


i tbsp. 


y 


14.0 


0.03 




12.3 


49 


Tapioca, pearled . 


i cup 


6K 


184.0 


0.4 






159.5 


640.0 


Tapioca, minute . 


i tbsp. 


y 


14.0 


0.03 






12.2 


490 


Tomatoes .... 


i tbsp. 


y+ 


15.0 


0. 2 





03 


0.6 


4.0 


Tomatoes .... 


i cup 


8 


227.0 


2.7 





5 


9-0 


510 


Tomatoes .... 


i medium 


5 


142.0 


0.5 





3 


3 


16.0- 




(whole to- 
















mato) 














Trout (edible portion) 


i serving 


3K 


100. 


17.8 


10.3 




164.0 


Trout (edible portion) 


i lb. 


16 


454 .0 


80.6 


46.7 




743 • o- 


Turnip 


i serving 


zy 


100. 


1.3 


O. 2 


8.1 


390 


Turkey (edible portion) 


i serving 


zy 


100. 


21. 1 


22 .9 




290.5 


Turkey (edible portion) 

W 
Walnuts, English . 


i lb. 


16 


454-0 


95-7 


1039 




1317-0 


i cup 


sy 


156.0 


25.8 


98.8 


25.1 


1093.0 


Walnuts, English . 


i meat 




1.0 


0.17 


O.63 


0. 16 


70 


Whey 


i glass 


6K" 


184.0 


1.8 


0.5 


9.3 


50.0 


Whitefish (ed. port.) . 


i serving 


zy 


100. 


22.9 


6.5 




150.0 


Whitefish (ed. port.) . 


i lb. 


16 


4540 


103.8 


29.4 




681.0 



INDEX 



Absorption, 38 

of carbohydrates, 40 
of fat, 41 

rate of, 42 
from large intestine, 48 
in intestines, 38 
in mouth, 38 
of protein, 38 
in stomach, 38 
Accessory foodstuffs. See Yitamines. 
Achylia gastrica, 343 

diarrhea in, 346 
diet in, limited protein, 344 
etiology of, 344 
gastritis and, diet in, 348 
Acid foods, 86 

in gastric juice, 29, 30 
hydrochloric, in gastric juice, 30 
Acidity, gastric, 374. See Gastric acid- 
ity. 
Acids, effect of, on emptying of stom- 
ach, 28 
in fruits, 242 
Acne rosacea, 431 

alcohol as cause of, 431 
chronic indigestion in, 431 
diet in, 432 

etiological factors in, 431 
vulgaris, 432 

blood sugar in, 432 
diet in, 432 
sweets in, 432 
Acromegaly, basal metabolism in, 63 

diet in, 612 
Acute yellow atrophy of liver, 419 
Addison's disease, diet in, 616 
Adolescent heart, diet in, 313 
Aged, alcoholic beverages for, 528 
animal food for, 526 
diet routine in, 528 
Fletcher's dietary routine for, 529 
food especially desirable for, 525 

requirement of 523 
foods for, preparation of, 527 
vegetable food for, 526 
Akoll biscuit in diabetes mellitus, 484 
Albumen water, 656 
Albumen, 166 
Albuminoids, 167 



Albuminuria, cantharides as cause, 445 
diet in, 446 

Karell, 446 
lactofarinaceous, 446 
milk, 446 
salt-poor, 446 
irritating oils in, 446 
orthostatic, 446 
renal irritants in, 445 
turpentine as cause, 445 
visceroptosis in, 445 
Alcohol, effect of, on hypertension, 315 
on stomach, 37 
food value of, 258 
Alcoholic beverages. See Beverages. 
Aleuronat, 657 
Alimentary canal, sensibility of, 37 

tract, rate of passage of food 
through, 46 
Alkaline foods, 86 

treatment of peptic ulcer, 360 

waters in chronic gastritis, 348 

Allen's treatment of diabetes mellitus, 

468, 476 
Almonds, composition of, 667 
Ambulatorv treatment of peptic ulcer, 

365 
American cheese, composition of, 662 
Amino-acids, absorption of in rectal 
feeding, 619 
in protein foods, 165 
Ammonia, excretion of, 50 
Amyloid kidney, diet in, 458 

liver, 419 
Anabolism, 17 
Anemia, 530 

action of iron in, 532 

theories of, 532 
basal metabolism in, 63 
diet in, 533 

green vegetable, 536 
protein-rich, 536 
salt-poor, 536 
etiology of, 530 

gastro-intestinal conditions in, 531 
hyperchlorhydria in, 531 
iron in, 532 

low protein as cause, 530 
pernicious, diet in, 535 
posthemorrhagic, diet in, 537 
rest in, 531 



684 



INDEX 



Anemia, secondary, treatment of, 535 
tea as cause of, 531 
wines and ales in, 534 
Aneurysm, diet in, 316 
Angina pectoris, diet in, 316 
Animal food, 660 

for aged, 526 
Anorexia, nervous, 559. See Nervous 

anorexia. 
Apoplexy, diet in, 550 
Karell diet in, 551 
overeating in, 551 
Apothecaries' measures, table of, 668 
and metric measure, relative value 

of, table of, 669 
weight, relative value of, table of, 

670 
weights, table of, 668 
Appendectomy, postoperative diet for, 

607 
Appendicitis, acute, 403 

gastric lavage in, 403 
moribund cases, 403 
non-operative cases, diet in, 

403 
nutrient enemata in, 404 
Ochsner's treatment in, 403 
opium in, 403 
peristalsis in, 405 
starvation in, 403 
chronic, constipation and, 405 

fermentable vegetables in, 406 
salines in, 405 
larval, 405 
Appetite, 31 

effect of, on digestion, 31 
factors which influence, 33 
juice, digestion in absence of, 32 
secretion of, 32 
Apple pie, composition of, 664 
Apples, changes in ripening, 242 

composition of, 666, 667 
Approximate measures, table of, 668 
Apricots, composition of, 666, 667 
Arrhythmia, diet in, 305 
Arrow-root gruel, 656 
Arteriosclerosis, diet in, 314 
"few protein," 314 
rules for, 315 
Arthritis, chronic infections, 589. See 
Rheumatism, chronic, 
deformans, calcium metabolism in, 
.596 
diet in, 596 
etiology of, 596 
high caloric feeding in, 598 
low calcium, diet in, 596 

protein allowance, 597 
reduction cures in, 598 
Artichokes, composition of, 665 
Articular rheumatism, acute, 587. See 

Rheumatism, acute articular. 
Artificial buttermilk, 655 



Artificial feeding, 276 

methods of, 618 
Ash of meat, composition of, 174 
Ash-free diet, 85 
Asparagus, composition of, 665, 666 

cream of, composition of, 668 
Assimilation limit, 211 
of glucose, 41 
Asthma, diet in, 323 

Chittenden low protein, 324 
feeding in, rules for, 324 
foods to avoid in, 324 
Athletes, diet for, 637 

carbohydrate, 638 
Chittenden's experiments in,. 

637 
fats in, 638 

food requirements for, 638 
foods to avoid, 640 
protein in, 637 
rules for, 640 
sugar in, 639 
Atony, gastric, 370. See Gastric atony, 
intestinal, 402. See Intestinal At- 
ony. 
Auto-intoxication, intestinal, 406. See 

Intestinal auto-intoxication.. 
Avoirdupois and metric weight, relative 
value of, table of, 670 

B 

Bacon, composition of, 661 
Bacteria, action of, in intestines, 42 
in stomach, 43 
in butter, 233 

quantity excreted per day, 43 
fermentative, 42 
in rm'lk, 158 
putrefactive, 43 
Bacterial changes in protein foods, 171 
Baking powder, 222 
Bananas, composition of, 224, 666 
Banting's cure in obesity, 498 
Barley, 215, 216 
gruel, 656 

meal and flour, composition of, 663. 
Bartlett's method of compounding for- 
mula, 285 
Basal metabolism, 60 

in acromegaly, 63 
age and, 67 
in anemia, 63 
calculation of, 62, 63, 64 
in cancer, 63 
in cretinism, 63 
determination of, 60, 61 
in diabetes, 63 
in goiter, 63 
in leukemia, 63 
in typhoid fever, 63 
unit of comparison of, 61 
variation of, with age, 62,65, 
66, 67 



INDEX 



685 



Bass, composition of, 661 
Bean soup, composition of, 667 
Beans, soy, 204 
Beechnut, composition of, 667 
Beef. See also Meat, 
broth, 185 

canned, composition of, 660 
cooked, composition of, 660 
fresh, composition of, 660 
meal, 657 

organs, composition of, 660 
retail cuts of, chart of, 176 
roasting of, 179 
soup, composition of, 667 
Beef-juice, composition of, 663 

in infant feeding, 287 
Beet sugar, 208 
Beets, composition of, 665 
Beriberi, 104, 541 
diet in, 542 
polished rice and, 542 
Berries, composition of, 666 
Beverages, 245-262 

alcoholic, 257. See also Teaj cof- 
fee, cocoa, 
composition of, 259 
for sick, 654 

albumen water, 656 
arrow-root gruel, 656 
artificial buttermilk, 655 
barley gruel, 656 
cereal gruels, 656 
cocoa shells, 656 
egg lemonade, 655 

nogg, 656 
farina gruel, 657 
flaxseed' tea, 654 
flour gruel, 656 
Irish moss jelly, 655 
koumyss, 655 

orange-albumen water, 654 
peptonized milk, cold process, 

655 
fully, 655 
ripened milk, 655 
wine whey, 655 
Biliary cirrhosis, diet in, 418 
Biscuits, 222 

Blackberries, composition of, 666, 667 
Blackfish, composition of, 661 
Blood, diseases of, diet in, 530 

uric acid in, in pneumonia, 319 
Blood-pressure, effect of foods on, 316 
Bloodvessels, diseases of, diet in, 314 
Blueberries, composition of, 667 
Bluefish, composition of, 662 
Boas gastric motor meal, 383 

(non-lactic acid-containing) test 
meal, 382 
Body surface, calculation of, 62 

chart for estimation of, 62 
Bologna, composition of, 661 
Boston crackers, composition of, 664 



Bouillon, composition of, 668 
Bovaird's diet in rheumatoid arthritis, 

597 

/3-oxybutyric acid in diabetes mellitus, 

465 
Brain workers, diet adapted to use of, 

637 
Brazil nuts, composition of, 667 
Bread, 221 

brown, composition of, 663 
corn, composition of, 663 
as food for children, 122 
in infant-feeding, 289 
leavening of, 22 1 
rye, composition of, 663 
wheat, composition of, 663 
Breakfast foods, 223 
Breast feeding, 268 

abnormal stools and, 273 
contra-indications to, 269 
gas and colic and, 272 
intervals of nursing, 269 
length of each nursing, 270 
mother's diet, 270 
normal stools, 272 
vomiting and, 272 
Brill's disease, 567. See Typhus fever. 
Bronchitis, acute, diet in, 320 
chronic, diet in, 321 

foods to avoid in, 322 
suitable for, 322 
Broth, beef, 185 

in infant-feeding, 287 
Broths, meat, 185 

Brussel sprouts, composition of, 666 
Buckwheat, 215, 216, 663 
Bulgarian bacilli, use of, in pneumonia, 

320 
Butter, 232 

bacteria in, 233 

beans, composition of, 665, 666 
composition of, 233, 662 
renovated, 233 
substitutes for, 233 
vitamine content of, 105 
Butterfish, composition of, 662 
Buttermilk, artificial, 655 

composition of, 662 
Butternuts, composition of, 667 



Cabbage, composition of, 665 
Cakes, 223, 664 

Calf's-foot jelly, composition of, 663 
Calcium content of foods, 94 

excretion of, 49 

requirement of man, 92 
Calculi in phosphaturia, diet for, 521 
California cheese, composition of, 662 
Caloric requirement of infant, 276 

value of food, 231 
Calories, 56. See Energy requirement, 
Metabolism. 



686 



INDEX 



Calories, one-hundred caloricportion, 57 
Calorimeter, 58, 59 
Calory feeding in insanity, 550 
Cammidge on toxicosis in diabetes mel- 

litus, 464 
Cancer, basal metabolism in, 63 

diet in, 634 

Centanni on, 635 
Candy, 210 

composition of, 665 
Cane sugar, 208 
Carbohydrates, 19 

absorption of, 40 

in rectal feeding, 621 

classification of, 207 

effect of, on protein requirement, 

79 

fermentation products in intestinal 
auto-intoxication, 407 

formation of fat from, 41 

in milk, 153 

subcutaneous feeding of, 624 
Carcinoma of stomach, 375. See Stom- 
ach, carcinoma of. 
Cardiac decompensation, diet in, 309 

disease, Karell cure in, 310 

Potter's modification of, 
310 
organic, diet in, 305 
relation of digestive disturb- 
ances to, 305 
tobacco and, 316 

disturbances, 305 

myasthenia, diet in, 313 
Carrots, composition of, 665 
Casein preparations, 200 
Casoid biscuit in diabetes mellitus, 486 
Catabolism, 17 

Catarrhal jaundice, acute, diet in, 416 
Cauliflower, composition of, 665 
Celery, composition of, 665 

cream of, composition of, 668 
Celluloses, 224 

Centanni on diet in cancer, 635 
Cereal gruels, 656 

in infants' food, 284 
Cerealine, composition of, 663 
Cereals as food for children, 122 

in infant feeding, 288 
Cerebral meningitis, 585 
Cerebrospinal meningitis, 585 
Cheddar cheese, composition of, 662 
Cheese, composition of, 199, 662 

digestibility of, 206 

types of, 200 
Cherries, composition of, 666, 667 
Cheshire cheese, composition of, 662 
Chestnuts, composition of, 667 
Chicken meat, composition of, 661 

sandwich, composition of, 668 

soup, composition of, 667, 668 
Children, energy requirement of, 117 

feeding of, planning meals for, 124 



Children, food habits of, 124 
foods for, 116, 122 

after two years, 116-121 

allowance of, 119 

cereals, bread, etc., 122 

eggs, 122 

fats, 123 

fruit, 123 

meat, 122 

milk, 122 
increase of weight in, 116, 117 
inorganic salts required by, 120 
protein requirement of, 118 
selection of diets for, after second 

year, 121 
vitamine requirement of, 120 
water requirement of, 121 
Chittenden's low protein diet in asthma,. 

324 

protein allowance in gout, 507 
Chlorine content of foods, 88 

requirement of man, 87 
Chlorosis, diet in, 533 

iron in, 532 

rest in, 531 
Chocolate, composition of, 251, 667 
Cholecystitis, acute, diet in, 421 
Cholelithiasis, 419 

alcohol in, 421 

avoidance of fermentation in, 42 r 

carbohydrates in, 421 

exercise in, 421 

fats in, 420 

meats in, 420 

olive oil in, 658 

postoperative diet in, 420 

prophylactic diet in, 420 

restricted sugars in, 421 
Cholera, acid drinks in, 592, 593 

diet in, rules for, 592 

drinks in, 593 

feeding in algid stage of, 592 
late stages of, 593 
middle stage of, 592 
rectal, 592 

fluids in, necessity for, 593 

Hayem's solution in, 593 

hypodermoclysis in, 593 
serum by, 593 

indigestible foods in, avoidance of,. 

592 , . . 

intravenous solution in, 593 

salines in, rectal, 593 
Chorea, diet in, 553 

etiology of, 553 

fattening foods in, 553 
Chronic infections, feeding in, 595 
Circulatory organs, diseases of, 305 
Cirrhosis, biliary, diet in, 418 

of liver, 417. See Portal cirrhosis. 
Citrated milk in carcinoma of stomach, 

Citron, composition of, 666 



INDEX 



687 



Cocoa bean, composition of, 251. 

composition of, 250, 567 
Cocoanuts, composition of, 667 
Cod, composition of, 661 
Cod-liver oil, 236 
Coffee, 247 

caffein in, 248 
caffein-free, 249 
effect of, 250 
preparation of, 248 
tannin and caffein extracted in 
preparation of, 249 
Cohnheim's diet in diarrhea, 395 
Cold storage of fish, 191 
Coleman's diet in pneumonia, 318 

milk mixtures in typhoid fever, 573 
Colic in artificially-fed infants, 291 
in breast-fed infants, 272 
mucous, 391 

chronic, 391 
diet in, 391 

Nothnagle's theory of, 391 
Colitis, acute, diet in, 389 
chronic, diet in, 390 

malnutrition in, 390 
membranous, diet in, 391 
Colon, passage of food through, 45 
Colostrum, 263 
Combe on intestinal auto-intoxication, 

407 
Comedones, diet in, 435 
Condensed milk, 156 
Congestion, hepatic, diet in, 416, 417 
Consomme, composition of, 668 
Constipating diet, 611 
Constipation, 293 
atonic, 398 

cheese in, 399 
desserts in, 399 
diet in, 398 
eggs in, 399 
fats in, 399 
fish in, 399 
fruits in, 399 
meat in, 399 
vegetables in, 398 
chronic, 397 

diet in, 399 
drinks in, 400 
mineral oil in, 401 
varieties of, 397 
obstructive, diet in, 400 
spastic, diet in, 400 
Corn, composition of, 215, 216, 665, 666 
cream of, composition of, 668 
green, 217 
meal, 215, 216, 663 
oil, 236 
starch, 217 
Cottage cheese, composition of, 662 
Cottonseed oil, 235 
Crackers, composition of, 664 
Cranberries, composition of, 666 



Cream, 231 

cheese, composition of, 662 
pie, composition of, 664 
Creatinine, excretion of, 51 
Cretinism, basal metabolism in, 63 

diet in, 616 
Cucumbers, composition of, 665 
Currants, composition of, 666, 667 
Custard pie, composition of, 664 
Cyclic vomiting, feeding during, 300 
Cystitis, diet in, 457 



Dairy products, composition of, 662 
Dates, composition of, 667 
Decompensation, cardiac, diet in, 309 
Deficiency diseases, diet in, 539 
Delafield's mixture in acute gastritis,. 
346 
mixture in fever, 564 
in influenza, 587 
Delirium tremens, diet in, 558 
Dental carries, causes of, 633 

condensed milk as, 633 
diet in, 633 
occurrence of, 633 
poorly-balanced diet in, 633 
Dermatitis, 434 

herpetiformis, diet in, 434 
exfoliative, diet in, 434 
Dextrose. See Glucose. 
Diabetes insipidus, 459 

determination of urinary chlo- 
rides in, 459 
diseases of hypophysis in, 459. 
low protein diet in, 460 
pituitrin in, use of, 459 
restriction of fluids in, 459 
salt-poor diet in, 460 
mellitus, acetone bodies in, 465 

adrenalin and sugar produc- 
tion, 464 
Akoll biscuit in, 484 
alcohol in, 483 

"days" in threatened 
coma, 475 
alimentary glycosuria and, 463 
alkaline reserve in, 465 
Allen's treatment of, 468, 476 
baked custard in, 487 
basal metabolism in, 63 
Benedict's solution in, 468 
/3-oxybutyric acid in, 465 
bran biscuits in, 487 
bread-and-butter diet in, 475 

substitutes in, 485 _ 
Cammidge on toxicosis in, 464. 
carbohydrate equivalents in,. 
472 
tolerance in, 481 
finding of, 468 
case record in, 481 



688 



INDEX 



Diabetes mellitus, Casoid biscuit in, 486 
classification of cases of, 469 
Claude Bernard and sugar pro- 
duction, 462 
coma not associated with keto- 

nuria, 464 
complicated by gout, 489 

by nephritis, 491 
cranberries in, 487 
diabetic flours in, 484 

milk (Wright) in, 486 
diets in, 469 

for obesity with, 490 

list of, 473 
in elderly people, 489 
exercises in, 481 
fasting in, 480 

fat metabolism and ketonuria 
in, 465 

a source of sugar in, 465 

tolerance in, 465 
foods in, carbohydrate content 
of, 472 

prohibited, 472 
Foster's carbohydrate units in, 

473. 
Geyelin's 15:30:30 formula, 

478 
glandular theory of, 462 
gluten meal biscuits in, 485 
glycosuria in, 460 
green days in, 470 
hyperglycemia in, 466 

without glycosuria, 460 
ice cream in, 487 
Joslin's resume of Allen's 

treatment of, 483 
ketonuria and sugar tolerance 

in, 469 
Lowe and sugar production in, 

461 
metabolism in, 460, 462 
carbohydrate, 460 
fat, glycosuria and, 465 
protein, glycosuria and, 
462 
nitrogen balance in, 464 
oatmeal days in, 471 

recipes in, 471 
pancreas in, 461 
pathological physiology in, 460 
potato diet in, 475 
protein tolerance in, 483 
relation of amino-acids, ace- 
tone bodies, and sugar, 463 
severe cases with marked keto- 
nuria, 474 
soja-bean meal biscuits in, 485 
special recipes in, 485 
standard strict diet, 469 

with restricted protein, 
470 
suprarenals in, 462 



Diabetes mellitus, treatment of, 467, 468 
of medium severe cases, 

474 
of mild cases, 468 

use of 5, ,io, 15, 20 per cent, 
vegetable in, 481 

von Noorden and sugar pro- 
duction, 468 
"set" of days in, 475 

weekly fast days in, 484 
• in the young, 489 
Diarrhea, 291, 393 

in achylia gastrica, 346 
diet in, 394 

Cohnheim's, 395 
etiology of, 393 

drugs and, 394 

food idiosyncrasy and, 394 

gastrogenic, 393 

habits and, 394 

irritative, 393 

nervousness, 394 

pancreatic, 394 

toxic, 393 
in exophthalmic goiter, diet for, 615 
foods absolutely forbidden in, 396 

allowed in certain cases of, 395 

recommended in, 395 

to avoid in, 395 
Diet, animal vs. vegetable, 145 
ash-free, 85 

in deficiency diseases, 539 
in diseases of blood, 530 

of bloodvessels, 314 

of ductless glands, 612 

of gall-bladder, 414 

of genito-urinary system, 436 

of intestines, 384 

of liver, 414 

of nervous system, 547 

of pancreas, 422 

of skin, 425 

of stomach, 335 
effect of absence of inorganic salts 
on, 85 _ 

on excretion of uric acid, 51 

on milk, 115 
eggs in, place of, 194 
essential constituents of, 130 

factors in, 102 
fats in, importance of, 228, 230 
in fattening cures, 514 
fish in, place of, 188 
for athletes, 637 
for brain workers, 637 
for singers, 636 
for speakers, 636 
lactation and, 115 
legumes in, value of, 202 
low protein vs. high protein, 82 
in organic cardiac disease, 305 
in old age, 522 
in pregnancy, 626 



INDEX 



689 



Diet in relation to surgical operations, 

599 

sugar in, value of, 212 

vegetarian, 645, 648 

wheat in, place of, 218 
Dietaries, standard, 80 
Dietary cures, 645 

precautions, 644 
Digestibility, 52 

comparative, of foods, 53 

ease of, 52, 53 
Digestion, 23 

in absence of appetite juice, 32 

effect of appetite on, 31 

factors modifying, 52 

of fat in stomach, 31 

gastric, 27 

intestinal, 35 

measure of, 52 

of nucleoproteins in intestines, 36 

oral, 23 

of protein in stomach, 30 

salivary, in stomach, 26 
Digestive disturbances, cardiac disease 
and, 305 

neuroses, diet in, 557 
Dilatation, gastric, olive oil in, 658 
Distilled liquors, 262 
Doughnuts, composition of, 664 
Dried milk, 157 

Duck meat, composition of, 661 
Ductless glands, diseases of, diet in, 612 
Duodenal feeding in nervous anorexia, 

559 . 
in peptic ulcer, 367 

Einhorn's method, 367 
in portal cirrhosis, 418 
Duodenum, hemorrhage from, diet 
after, 369 
ulcer of, 349. See Peptic ulcer. 
Dutch cheese, composition of, 662 
Dynamic effect of food, 68 
Dysentery, acute, diet in, 389 
chronic, diet in, 390 



E 



Eczema, 428 

acute, diet in, 429 

in children, 430 

chronic, 429 

Chittenden protein allowance 

in, 430 
foods to avoid in, 430 

dietetic faults in, 428 

frequency of, 428 

in nurslings, nutrose in, 430 

salt retention in, 430 

urinary acidity in, 431 
Edema in cardiac disease, diet for, 311 
Edgar's postpartum diet list, 630 
Eels, composition of, 662 

44 



Egg crackers, composition of, 664 
in infant feeding, 288 
lemonade, 655 
nogg, 656 

sandwich, composition of, 668 
Egg-gold 195 

Eggplant, composition of, 665 
Egg-white, 195 
Eggs, 194-199 

composition of, 195, 662 
cooking of, 196 
in diet, place of, 194 
digestibility of, 197 
as food for children, 122 
preserved, 198 
substitutes for, 199 
Einhorn's method of duodenal feeding 

in peptic ulcer, 367, 368 
Emphysema, diet in 332 
Fletcherism in, 320 
Empyema, diet in, 325 
Endogenous food poisoning, 641 
Energy metabolism of infant, 113 
requirement, 56 
average, 71 
of children, 72, 117 
determination of, 59 
efficiency of human body, 69 
factors affecting, 68 
occupation and, 72 
Enteritis, acute, 385 

classification of, 385 
diet in, 385 

forbidden foods in, 386 
chronic, 386 
diet in, 387 

Schmidt's test, 387 
modified, 388 
Enteroclysis in yellow fever, 591 
Enzyme action, 23 

factors which affect, 24 
nature of, 23 
nomenclature of, 23 
Enzymes in gastric juice, 29 
of intestines, 35, 36 
of pancreatic juice, 36 
in stomach, 29 
Epidermal excretion, 49 
Epilepsy, 548 

bromide salts in, 549 

diet in, 548 

effect of high protein diet on, 548 

indol in urine in, 548 

low protein diet in, 549 

occurrence of, in carnivora, 548 

in herbivora, 548 
starvation and, 549 
Erepsin, 36 
Erythema, 432 

anaphylaxis and, 433 
diet in, 433 
foods to avoid in, 433 
Esophagus, stenosis of, olive oil in, 658 



690 



INDEX 



Ewald-Boas test breakfast, 381 
Ewald test dinner, 381 
Excretion, 48 

of ammonia, 50 
of calcium, 49 
of creatine, 51 
of creatinine, 51 
epidermal, 49 
of nitrogen, 49 
of urea, 50 
of uric acid, 51 

effect of diet on, 51 
Exfoliative dermatitis, diet in, 434 
Exogenous food poisoning, 642 
Exophthalmic goiter, avoidance of io- 
dine-rich foods in, 614 
of too rapid gain in weight 
in, 615 
diarrhea in, 615 
diet in, 614 

for special indications, 615 
effect of proteins in, 615 
etiology of, 613 
Falta on metabolism in, 613 
glycosuria in, 615 
high calory feeding in, 614 
hyperglycemia in, 615 
inanition in, diet in, 616 
milk of thyroidectomized goats 

in, 614 
neurogenic origin of, 613 
nitrogen-free -food in, 614 
toxic origin of, 613 
Extracts, flavoring, 245 
malt, 261 
meat, 185 



Farina, composition of, 663 

gruel, 656 
Fasting, 126 
Fat, absorption of, 41 
rate of, 42 
in rectal feeding, 621 

caloric value of, 231 

digestion of, in stomach, 31 

m fish, variation of, 189 

formation of, from carbohydrates, 

4 1 
requirement of infant, 277 

Fat-soluble A, 20. See Vitamine 

Fats, 13, 20, 227-237 

in diet, importance of, 228, 230 

digestibility of, 230 

digestion of, 228 

effect of, on protein requirement, 

79 
in food for children, 123 
melting point of, 229 
in milk, 153 
subcutaneous feeding of, 624 



Fattening cures, 514 

alcohol in, 517 

carbohydrate in, 516 

cereals in, 516 

essentials of, 514 

fat in, 517 

foods used in, 515 

increase of nitrogen surplus, 

515 

maintenance diet in, 514 

nitrogen needs in, 515 

protein in, 515 

suggestion for diet in leanness, 
5i8 

surplus food*in, 515 
Fatty heart, diet in, 312 

liver, 418. See Liver, fatty. 
Feces, 46 

effect of nature of food on, 46 
putrefaction and, 44 
reaction of, 48 
Feeding, artificial, 282 

methods of, 618 
breast, 268 

of children, planning meals for, 124 
in disease, 305 
intravenous, 625 
mixea, 273 
normal, 129 
palatability and, 129 
rectal, 618 
subcutaneous, 623 
of unconscious patients, 640 
Fermentative bacteria, 42 
Fever, acidosis in, 564 
alcohol in, 566 
basal metabolism in, 70 
beverages in, 566 
caloric needs in, 562 
carbohydrate requirements in, 562 
citrated milk in, 564 
Delafield's mixture in, 564 
dextrinization of starch in, 564 
diet in, 563 

egg preparations in, 565 
fat absorption in, 562 
fats in,' 566 
feeding in, 562 

intervals of, 566 
food requirements in, 562 
heat loss favored by, 561 

production in, 561 
increased, 561 
maintaining body weight and, 562 
malarial, diet in, 584 
maltose preparations in, 564 
Martin's milk in, 564 
metabolism of, 562 

fasting in, 560 
milk preparations in, 564 
nitrogen in, elimination of, 563 
nitrogenous equilibrium in, 563 
protein in, 564 



INDEX 



691 






Fever, protein in, intake in, moderate, 

564 . 

requirements in, 562 
purine foods in, 563 
regulation of body temperature in, 

560 
relation of temperature to infec- 
tion, 561 
scarlet, diet in, 584 
total metabolism and body tem- 
perature, 561 
typhoid, 568. See Typhoid fever, 
typhus, 567. See Typhus fever, 
water drinking in, 561 
yellow, 590. See Yellow fever. 
Figs, composition of, 666, 667 
Filberts, composition of, 667 
Finney's diet list following gastro- 
enterostomy, 605 
Fish, 188-192 

canned, composition of, 662 
cold storage of, 197 
composition of, 189 
cooking of, 197 
in diet, place of, 188 
digestibility of, 192 
fat in, variation of, 189 
fresh, composition of, 661 
poisoning, 642 
preserved, 191 

composition of, 662 
in season, 190 
shell, kinds of, 188^ 
Fischer's alkaline solution in nephritis, 

.445 

Fisher's table of one hundred calory 
portions, 671 

Flaked wheat, composition of, 663 

Flavoring extracts, 245 

Flaxseed tea, 654 

Fletcherism, 649 

appetite satisfaction in, 650 
economic assimilation in, 650 
in emphysema, 323 
fuel value of food in, 652 
importance of taste in, 650 
liquid intake in, 651 
mouth digestion in, 650 
nitrogen intake in, 651 
number of meals daily, 650 
•stools in, 651 
U. S. Army regulations and, 650 

Fletcher's dietary routine for aged, 529 

Flies, sickness and, 654 

Flour gruel, 656 

Folin-Denis method of reduction in 
obesity, 502 

Food, absorption of, after gastroenter- 
ostomy, 604 
adjuncts, 244 
animal, 660 

consistency of, on passage from 
stomach, 54 



Food, cost of, 136 

relative, 138 
definition of, 17 

determination of caloric value of, 57 
dynamic effect of, 68 
economics, 129 

especially desirable for aged, 525 
habits of children, 124 
infants', increase of, 283 

preparation of, 283 
nutritive value of, calculated for 
cooking small portions, table of, 

677 
passage of, through alimentary 
tract, 46 
colon, 45 
poisoning, 641 

endogenous, 641 
exogenous, 642 
requirement of aged, 523 
in lactation, 115 
in pregnancy, 112 
Food-stuffs, caloric value of, 56 

functions of, 18 
Foods. See Protein -rich foods; carbo- 
hydrate-rich foods; fat-rich foods 
acid, 86 
alkaline, 86 
artificial, 657 

aleuronat, 657 
beef meal, 657 
nutrose, 657 
peptones, 657 
plasmon, 657 
roberat, 657 
somatose, 657 
tropon, 657 
breakfast, 223 
calcium content of, 94 
carbohydrate-rich, 207 
chlorine content of, 88 
classification of, 149 
digestibility of, comparative, 53 
fat-rich, 227-237 
for children, 122 

allowance of, 119 
iron content of, 96 
passage of, from stomach, rate of, 53 
phosphorus content of, 91 
protective, 107 
relative economy of, 141 
valuable for, salts, vitamines, wa- 
ter and bulk, 238-262 
vegetable, composition of, 663 
Foster's carbohydrate units in diabetes 

mellitus, 473 
Frankfurt sausage, composition of, 661 
Fructose, 210 

Fruit cake, composition of, 664 
cures, 652 

as food for children, 123 
sugar, 210 
Fruits, 238-244 



692 



INDEX 



Fruits, acids in, 242 

composition of, 239, 240, 666 

cooking of, 242 

place of, in diet, 238 
Functional cardiac disturbances, 305 

nervous diseases, diet in, 551 
Furunculosis, diet in, 43,^ 



Galisch 's cure in obesity, 502 
Gall-bladder, diseases of, 414 
alcohol in, 415 
avoidance of spirits in, 416 
condiments in, 415 
dietetic prophylaxis in, 415 
foods to avoid in, 415 
irritating oils in diet of, 415 
Strauss's levulose test in, 415 
operations, postoperative diet for, 
610 
Gas in artificially-fed infants, 291 

in breast-fed infants, 272 
Gastric acidity, organic, diet in, 374 
atony, 370 

in chronic gastritis, 347 
diets in, 371, 372 
mild, diet in, 374 
severe, diet in, 372 
Wegele's diet in, 373 
Wier Mitchell rest cure in, 372 
digestion, 27 

dilatation, acute, vomiting from, 
diet in, 608, 
chronic, management of, 379 
diet when atony complicates, 

379 
lavage in, 378 
olive oil in, 658 
hyperacidity, diet in, 338, 341 
in diseases of skin, 425 
foods to avoid in, 342 
olive oil in, 658 
reduction of, by diet, 340 
hypersecretion, diet in, 342 
hypoacidity, diet in, 343 
juice, acid in, 29, 30 

action of, on milk, 31 
enzymes in, 29 
hydrochloric acid in, 30 
quantity per day, 30 
stimuli to secretion, 32 
motor function, impaired, 370. See 
Gastric atony, 
meals, 382 

Boas', 382 

Hausman's stagnation, 

382 
Schmidt-Strassburger, 383 
test supper, 382 
von Leube's, 382 
water test for acidity, 382 
neuroses, classification of, 379 



Gastric neuroses, motor, diet in, 381 
secretory, diet in, 380 
sensory, diet in, 380 

Weir Mitchell cure in, 381 
operations, preoperative diet in, 

600 
test meals, 381 

Boas (non-lactic acid con- 
taining), 382 
Ewald-Boas test break- 
fast, 381 
Ewald test dinner, 381 
Germain-See, 381 
Klemperer's, 381 
Reigel's test dinner, 381 
Salzer's double, 382 
Gastritis, achylia gastrica and, diet in, 
348 
acute, 346 

Delafield's mixture in, 346 
demulcent drinks in, 347 
diet in, 346 
starvation in, 346 
Vichy in, 346 
chronic, alkaline waters in, 348 
atony in, 347 
diet in, 347 

High Rock water in, 348 
hyperacidity and, diet in, 347 
hypoacidity and, diet in, 348 
Gastroduodenitis with jaundice, diet in, 

416 
Gastro-enterostomy, absorption of food 
after, 604 
in carcinoma of stomach, 377 
diet after, 601 

Finney's, 605 
von Leube's, 603 
Gastrostomy in carcinoma of stomach, 

377 
Gavage in nervous anorexia, 559 
Gelatin, 186 
Genito-urinary system, diseases of, diet 

in, 436 
Germain test meal, 381 
Germain-See diet in obesity, 500 
Gevelin's formula for diabetes mellitus, 

478 
Ginger snaps, composition of, 664 
Gingerbread, composition of, 664 
Globulin, 167 
Glucose, 209 

assimilation limit of, 41 

utilization of, 41 
Glutens, composition of, 663 
Glycogen in meat, 173 
Goiter, basal metabolism in, 63 

exophthalmic, 613. See Exoph- 
thalmic goiter. 
Goldberger on diet in pellagra, 544 
Gonorrhea, alcohol in, avoidance of, 457 

alkaline waters in, 457 

diet in, 457 



INDEX 



693 



Gonorrhea, diet in, milk, 457 

foods to avoid in, 457 
Gout, 504 

acute, diet in, 510 

starvation in, 510 

alcohol in, 509 

alkaline waters in, 509 

blood in, 506, 508 

carbohydrates in, 509 

Carlsbad waters in, 513 

Chace and Fine on use of radium 
in, 514 

Chittenden's protein allowance in, 

507 
chronic, diet in, 511 
clinical, use of meats in, 508 
determination of purine tolerance 

in, 511 
diagnosis of, dietary, 508 

Von Noorden and Schleip's 
method of, 507 
diet in, accessory, 511 

main, 510 
etiology of, 504 
foods in, 508 
guanin in, 504 
Hot Springs, Va., for, 513 
hypoxanthin in, 504 
low purine intake in, 507 
Marienbad water in, 513 
metabolism in, 504 

purine, 504 
mineral waters in, 513 
purine bodies in foods, 513 
foods in, 510 
vitamines and, 506 

equivalents in, 511 
radio-active waters in, 514 
„ radium emanations in, 514 
Rhein wine in, 509 
salt in, 509 

Saratoga Springs for, 513 
sodium biurate in, 509 
theobromine in, 504 
thymus in test diet, 508 
uric acid in, endogenous, 505 
exogenous, 505 
production of, 505 
Vichy in, 513 
whiskey in, 509 

White Sulphur Springs for, 513 
xanthin in, 504 
Graham crackers, composition of, 664 

flour, composition of, 662 
Grains, 214. See Individual grains. 
Grape cures, 653 
Grapes, composition of, 666 
"Green sickness," 530 

turtle soup, composition of, 668 
Grippe, 586. See Influenza. 
Guinea-hen meat, composition of, 661 



H 



Haddock, composition of, 662 
Halibut, composition of, 662 
Ham, composition of, 661 

salad, composition of, 668 
Hare's dietetic treatment of migraine, 

552 
Hash, composition of, 668 
Hausman's gastric motor meal, 382 
Hayem's solution in cholera, 593 
Headaches, periodic, 551. See Mi- 
graine. 
Heart, fatty, diet in, 312 

senile, diet in, 313 
Heat, action of, on milk, 159 

effects of, on protein foods, 169 
Hemophilia, diet in, 538 
Hemorrhage, intestinal, diet in, 392 
Hemorrhoids, diet in, 412 

postoperative diet for, 610 
Hepatic congestion, acute, diet in, 416 

chronic, diet in, 417 
Herring, composition of, 662 
Hickory nuts, composition of, 667 
High Rock water in chronic gastritis, 

348 . 

Hirschsprung's disease, diet in, 413 
Hominy, composition of, 663 
Honey, composition of, 665 
Hormone, 33 

Huckleberries, composition of, 666 
Hunger contractions in disease, 35 

origin of sensations of, 34 
Hydrochloric acid in gastric juice, 30 
Hyperacidity, foods to avoid in, 342 

gastric, diet in, 348 
olive oil in, 658 

reduction of, by diet, 340 
Hyperchlorhydria, diet in, 338 

Kauffman's classification of etiol- 
ogy of, 338, 339 
Hyperidrosis, diet in, 435 
Hypersecretion, gastric, diet in, 342 
Hypertension, 315 

boiled meats in, 315 

diet in, 315 

effect of alcohol on, 316 

of foods on blood-pressure, 316 

extractives in, 316 

parahydroxyphenylethvlamine in, 

315' 
purine-free bodies in, 316 
Hydrotherapy' in nervous anorexia, 559 
Hydrothorax, diet in, 325 
Hypoacidity, diet in, 343 
Hypodermoclysis in acute peritonitis, 
594 

I 

Ice cream, composition of, 664 
Indian meal pudding, composition of, 
664 






694 



INDEX 



Indican, product of putrefaction, 43 
Indigestion, diet in, 336 
Indol, product of putrefaction, 43 
Infant, artificially-fed, abnormal stools 
in, 291 

colic in, 297 

gas in, 291 

vomiting in, 290 
breast-fed, abnormal stools in, 273 

colic in, 272 

gas in, 272 

normal stools in, 272 

vomiting in, 272 
caloric requirement of, 276 
carbohydrate requirement of, 278 
energy metabolism of, 113 
fat requirement of, 277 
feeding, beef juice in, 288 

bread in, 289 

broth in, 287 

egg in, 288 

high fat mixtures in, 285 

orange juice in, 287 

proprietary foods in, 280 

rice in, 289 

salts in, 280 

starch in, 279 

sugar in, 278 

table of formulae for, 286 

vegetables in, 288 

water in, 280 
foods, cereals in, 284, 288 

increasing of, 283 

preparation of, 283 

protein requirement of, 277 
protein requirement of, 277 
Influenza, Delafield's mixture in, 587 

diet in, 587 
Inorganic salts, 20, 84 

effect of absence of, in diet, 85 

function of, 84 

required by children, 120 
Insanity, calory feeding in, 550 
food preparation in, 549 
forcible feeding in, 549 
gavage in, 549 
mouth gag in, 550 
suralimentation in, 550 
Insommia, ale in, 558 

avoidance of tea and coffee in, 558 
diet in, 558 

disturbed digestion and, 558 
drugs in, 558 
habit in, 557 
hot cocoa in, 558 
hygiene in, 557 
light supper in, 558 
malted milk in, 558 
preventive methods in, 557 
special foods in, 558 
Intestinal atony, diet in, 402 
auto-intoxication, 406 



Intestinal auto-intoxication, animal 

experimentation in, 407, 408 
associated conditions in, 410 
buttermilk in, 410 
carbohydrate fermentation 

products in, 407 
change of scene in, 412 
Combe on, 407 
diet in, farinaceous, 410 

for chronic constipation, 

r 4 - I]C 

for intestinal stasis, 411 
meatless, 410 
dietetic indication in, 409 
exercise in, 412 
farinaceous food allowance in, 

410 
foods to avoid in, 410 

to take in, 410 
grape juice in, 411 
indicanuria in, 408 
indol in, 408 

excretion in, 408 
indoxyl sulphuric acid in, 408 
laxatives in, 411 
nitrogenous food allowance in, 

409 
phenol in, 408 

excretion in, 408 
protein putrefaction in, 407 
relation of bacteria to, 408 
sample menus in, 410 
skatol in, 408 
bacteria, 42 
digestion, 35 
distention, postoperative, diet in, 

609 
hemorrhage, diet in, 392 
lesions, postoperative diet for, 606 
neuroses, diet in, 396 
Intestine, large, absorption from, 48 
Intestines, absorption in, 38 
bacteria in, action of, 42 
diseases of, diet in, 384 
enzymes of, 35, 36 
movements of, 36 
nucleoproteins in, digestion of, 36 
ulceration of, diet in, 392 
Intravenous feeding, 625 
Intubation, feeding after, 611 
Invert sugar, 210 
Iodine requirement of man, 98 
Irish moss jelly, 655 
Iron in anemia, 532 

content of foods, 96 
in green vegetables, 241 
inorganic vs. organic, 97 
requirement of man, 97 
water, 254 
Irritable stomach with vomiting, diet 
in, 338 



INDEX 



695 



Jams, 210, 211 

Jaundice, acute catarrhal, diet in, 416 

Jellies, 210, 211 

Johnson's classification of dermatoses, 

425 
Joslin's treatment of diabetes mellitus, 

483 
Juices, meat, 185 
Julienne, composition of, 668 
Juvenile phosphaturia, 520 



Karell cure in cardiac disease, 310 

Potter's modification 
of, 310 
diet in apoplexy, 551 
in nephritis, 452 
in portal cirrhosis, 417 
Kauff man's classification of etiology of 

hyperchlorhydria, 338, 339 
Kausch's solution for intravenous feed- 
ing, 625 
Keating's diet in neurasthenia, 554 
Kendall's bacteriological experiments 

on typhoid fever, 570 
Kidney, amyloid, diet in, 458 
Kinnicutt's diet in typhoid fever, 573 
Klemperer's test meal, 381 
Koumyss, 655 

composition of, 662 



Lactation, diet in relation to, 115 

food requirements in, 115 
Lactose, 209 
Lamb, cooked, composition of, 660 

fresh, composition of, 660 
Laparatomy, preoperative diet in, 599 
Lard, 235 

Leavening of bread, 221 
Legumes, composition of, 202, 204 

in diet, value of, 202 

digestibility of, 205 

preparation of, 205 
Lemon pie, composition of, 664 
Lemons, composition of, 666 
Lenhartz's diet in peptic ulcer, 353 
Lentils, composition of, 665 
Lettuce, composition of, 665 
Leube's formula for rectal feeding, 620 
Leukemia, basal metabolism in, 63 

diet in, 537 

gavage in, 537 
Lichi nuts, composition of, 667 
Limburger cheese, composition of, 662 
Lipins, 19. See Fats. 
Liquors, distilled, 262 

malt, 260 
Lithia water, 253 



Liver, acute yellow atrophy of, 419 
amyloid, 419 

cirrhosis of, 417. See Portal cir- 
rhosis, 
diseases of, 414 

alcohol in, 415 

avoidance of spirits in, 416 
fatty, adiposis and, 418 

condiments in, 415 

diet in, 418 

dietetic prophylaxis in, 415 

fat food in, 418 

foods to avoid in, 415 

function of, 415 

irritating oils in diet of, 415 

Strauss's levulose test in, 415 

test for hepatic function of, 

, 4 J 4 
Lockwood's modification of von Leube's 

diet in peptic ulcer, 351 
Lowe on sugar production in diabetes 

mellitus, 461 
Lowenburg's conclusions on NaCl, 444 
Lungs, diseases of, feeding in, 318 



M 



Macaroni, composition of, 223, 663 . 
Macaroons, composition of, 664 
Mackerel, composition of, 662 
Marmalade, composition of,. 667 
Malarial fever, diet in, 584 
Malt extracts, 261 

liquors, 260 

sugar, 210 
Maltose, 210 

Manson on diet in sprue, 631 
Maple sugar, 210 
Martin's milk in fever, 564 
Mastication, 25 
Meals for children, planning of, 124 

planning of, 131 
Measles, avoidance of rough food in, 
586 

diet in, 586 
Measures and weights, table of, 668 
Meat, 172-183 

beef, retail cuts of, chart of, 176 
roasting of, 179 

broths, 185 

color of, 173 

composition of ash of, 174 

cooking of, changes in composition 
result of, 181 
chemical changes in, result of, 

180 
effect on, 177 
kinds of, 178 

digestibility of, 180-183 

extracts, 185 

flavor of, 173 

as food for children, 122 

glycogen in, 173 



696 



INDEX 



Meat juice, 185 

percentage of lean with fat and 

bone in, 174 
poisoning, 642 
preparations, 183 
stew, composition of, 667 
substitutes, 648 
Menus, 131. See also Meals, 
abnormal, 135 
for family, 139 
Metabolic nitrogen, 46 
Metabolism, 17 

affected by activity or disease, 63, 

70 
basal, 60 

in acromegaly, 63 
in anemia, 63 
calculation of, 62, 63, 64 
in cancer, 63 
in cretinism, 63 
determination of, 60, 61 
in diabetes, 63 
in goiter, 63 
in leukemia, 63 
in typhoid fever, 63 
unit of comparison of, 61 
variation of, with age, 62, 65, 
66, 67 
in diseases of skin, 425 
energy of infant, 113 
in rectal feeding, 619 
sulphur, in scurvy, 541 
of vegetarians, 644 
Metric and apothecaries' measure, rela- 
tive value of, table of, 669 
weight, relative value of, table 
of, 670 
and avoirdupois weight, relative 
value of, table of, 669 
Migraine, carbon equilibrium in, 553 
convulsions and, 552 
decayed teeth and, 552 
diet in, Hare's, 552 

low carbonaceous, 552 

protein, 552 
meat-free, 552 
purine-free, 552 
vegetarian, 552 
etiology of, 551 
exercise in, 552 
neurosis in, 552 
relation of diet to, 551 
Milk, 150 

action of gastric juice on, 31 

of heat on, 159 
antiscorbutic properties of, not 
bacteria in, 158 
carbohydrates of, 153 
chemical properties of, 151 
citrated, in carcinoma of stomach, 

376 
coagulation of, 161 
composition of, 663 



M ilk, composition of, effect of diet on, 1 15 
variations in, 155 
condensed, 156 
diet in nephritis, 450 
digestion of, 160 
dried, 157 
fats of, 153 

as food for children, 122 
influence of temperature on, 158 
passage of, through stomach, 29 
peptonized, cold process, 655 

fully, 655 
ripened, 655 
salts of, 154 
sugar, 209 
woman's, 263 

characteristics of, 264 
composition of, 265 
effect of diet on, 268 
quantity of, 264 
Miller's diet in nephritis, 450 
Mince pie, composition of, 664 
Mincemeat, composition of, 668 
Mineral water, 252 
Mitchell, J. K., diet in neurasthenia,. 

556 
Weir, rest cure in gastric atony, 372 
neurosis, 381 
treatment of nervous anorexia,. 

559 
of neurasthenia, 555 
Mixed feeding, 273 

Mock turtle soup, composition of, 668 
Molasses, composition of, 665 

cookies, composition of, 664 
Mosenthal's modification of Schlager's 

test-day in nephritis, 440 
Mouth, absorption in, 38 
Mucous colic, 391. See Colic, mucous.. 
Muffins, 222 

Mulligatawny, composition of, 668 
Murphy drip in acute peritonitis, 594 
peptic ulcer and, 350 
in tetanus, 590 
Mushrooms, composition of, 665 
Muskmelons, composition of, 666 
Mutton, cooked, composition of, 661 

fresh, composition of, 661 
Myasthenia, cardiac, diet in, 313 

gastrica, 370. See Gastric atony. 
Myxedema, diet in, 616 



N 



Nectarines, composition of, 666 
Nephritis, 436 

acidosis in, 444 
acute, alcohol in, 448 

alkaline mixtures in, 445 
catharsis in, 446 
colon irrigations in, 446 
diet in, 447 

accessories to, 448 



INDEX 



697 



Nephritis, acute, diet in, milk, 447 
hot packs in, 449 
hypodermoclysis in, 446 
infectious diseases in, 448 
potash salts in, 447 
protein allowance in, 447 
toxic, 448 
water in, 446 
albuminuria in, 445 
alkaline reserve in, 437 
anaphylaxis as cause of, 436 
chronic, diet in, 450 

in edema, 451 
for nitrogen retention, 451 
Karell, 452 
management of, 449 
milk, 450 
Miller's, 450 
Nothnagel's, 451 
salt-poor, 452 

retention, 452 
in uremia, 450 
nitrogen retention in, 450 
water drinking in, 450 

for flushing effect, 450 
classification of, 445 
declorination in, 443 
etiology of, 437 
excretion in, 438 

of sulphates and phosphates, 
442 
Fischer's alkaline solution in, 445 

theories on, 445 
food factor in production of, 438 
kidney functions in, 439 

tests in, 439 
low protein diet and blood-pressure, 

443 
Lowenberg's conclusions on NaCl, 

444 . 

mercuric, enteroclysis in, 449 

potassium bitartrate in, 448 
treatment of, 448 

Lambert and Patterson's, 

448 
\ogel's investigation on, 

448 
Mosenthal modification of Schla- 

ger's test day, 440 
NaCl concentration in, 445 
nitrogen elimination in, 443 

secretion in, 443 
protein content of certain foods, 455 
quantitative salt test in, 439 
salt content of certain foods, 454 

excretion in, 439, 441 

retention, diet in, 452 

starvation in, 444 
Schlager's test day in, 440 
sodium chloride excretion in, 442 
water drinking in, 441 

excretion in, 439, 442 

loss in, 442 



Nephrolithiasis, alkaline waters in, 458 
diet in, low purine, 458 
foods to avoid in, 457, 458 
water drinking in, 458 

Nervous anorexia after mental shock,. 

559 
diet in, 559 

duodenal feeding in, 559 
gavage in, 559 
hydrotherapy in, 559 
hygiene in, 559 
suggestion in, 559 
Weir Mitchell routine in, 559 
phosphaturia, 519 
system, diseases of, diet in, 547 
Nestle's food in neurasthenia, 556 
Neufchatel cheese, composition of, 662 
Neurasthenia, chronic intoxications in, 

554 

cod-liver oil in, 556 

diet in, 554 

Keating's, 554 

milk, 555 

J. K. Mitchell's, 556 

etiology of, 553 

infections in, 554 

lowered vitality in, 554 

Nestle's food in, 556 

raw meat soup in, 556 

Weir Mitchell routine in, 555 
Neuritis, diet in, 547 
Neurosis, intestinal, 396. See Intes- 
tinal neurosis. 
Nitrogen, excretion of, 49 

metabolic, 46 
Noodles, composition of, 663 
Nothnagel's diet in nephritis, 451 

theory of mucous colitis, 391 
Nucleoproteins, 168 

digestion of, in intestines, 36 
Nutrose, 657 
Nuts, 206 

composition of, 207, 667 



O 



Oatmeal, composition of, 663 

crackers, composition of, 664 
Oats, 215, 217 
Obesity, 491 

acidosis in cure of, 503 

Banting's cure, 498 

blood-pressure and, 495 

bronchitis and, 494 

buttermilk in, 497 

carbohydrate restriction in, 497 

cardiovascular disease and, 494 

causes of, 492 

constitutional, 492 

chopped beef in, 501 

diets in, 497 

maintenance, 492 
von Noorden's, 496 



698 



INDEX 



Obesity, Ebstein's dietary in, 499 
elderly people and, 494 
emphysema and, 494 
exercise in, 503 
fat restriction in, 497 
fluid restriction in, 498 
Folin-Denis method of reduction 

in, 502 \ 
food restriction in, 497 
foods allowed in, 497 
Galisch's cure in, 502 
Germain-See diet in, 500 
hill climbing in, 499 
hypertension and, 494 
hypopituitarism and, 492 
hypothyroidism and, 492 
indications for a cure, 493 
Metropolitan Life Insurance Com- 
pany's weight table, 493 
milk cure in, 500 
Oertel's cure in, 498 
protein allowance in, 497 
reduction cures in, 496 
objects of, 494 
Salisbury diet in, 501 

Tower-Smith's modifica- 
tion of, 501 
Schweninger's dietary in, 500 
starvation period in cure of, 503 
table of weight and height, 493 
Tibbie's height-weight tables, 495 

milk cure in, 500 
types of, 495 
von Noorden's cure, 496 
water drinking in, 503 
Ochsner's treatment of acute appen- 
dicitis, 403 
peritonitis, 594 
Oertel's cure in o'besity, 498 
Oil, cod-liver, 236 
corn, 236 
cottonseed, 235 
olive, 236 
vegetable, 235 
Orthostatic albuminuria, 446 
Okra, composition of, 665, 666 
Old age, diet in, 522 
Older children, feeding of, 296 
Oleomargarine, composition of, 234, 663 
Olive oil, 236 

in cholelithiasis, 658 
dietary uses of, 658 
in gastric dilatation, 658 

hyperacidity, 658 
in pyloric stenosis, 658 
in stenosis of esophagus, 658 
Onions, composition of, 665 
Orange juice in infant feeding, 287 
Orange-albumen water, 654 
Oranges, composition of, 666 
Organic cardiac disease, diet in, 305 
Osteomalacia, diet in, 529 
Oxaluria, diet in, 521 



Oxaluria, Spa treatment of, 522 
Oxtail soup, composition of, 668 
Oyster crackers, composition of, 664 

P 

Palatability, a factor in feeding, 129 
Pancreas, diseases of, 422 

alimentary glycosuria in, 422 
carbohydrate fermentation in, 

422 
carcinoma in, 422 
Einhorn's duodenal tube in, 

422 
fat absorption in, 422 
hyperglycemia in, 422 
indicanuria in, 422 
lack of amylase in, 422 
of trypsinogen in, 422 
Pancreatic juice, reaction of, 36 

enzymes of, 36 
Pancreatitis, acute, diet in, 422 

chronic, diet in, 423 
Panopeptones, 657 
Paratyphoid fever, diet in, 584 
Parsnip, composition of, 665 
Pea soup, composition of, 668 
Peaches, composition of, 666, 667 
Peanut, 205 

butter, composition of, 667 
Peanuts, composition of, 667 
Pears, composition of, 666, 667 
Peas, composition of, 665 
Pellagra, in, 543 

balanced ration in, 544 
diet in, 545 
dietetic theory of, 543 
etiology of, 543 

Goldberger's conclusions on, 544 
infectious theory of, 543 
maize theory of, 543, 545 
one-sided diet in, 544 
poor hygiene theory of, 543 
preventive diet for, 546 
Pepsin, 29 
Peptic ulcer, 349 

diets in, 349 

alkaline treatment and, 

360 
ambulatory, 365 
Lenhartz's, 353 
modified, 364 
Murphy drip and, 350 
von Leube's, 350, 550 

Lockwood's modifica- 
tion of, 351 
Sippy's, 360 
duodenal feeding in, 367 

Einhorn's method, 367, 
368 
transgastric feeding in, 367 
Peptones, 657 

Peptonized milk, cold process, 655 
fully, 655 



INDEX 



699 



Perch, composition of, 662 
Pernicious anemia, diet in, 535 
Peritonitis, acute, feeding in, postopera- 
tive, 594 
hypodermoclysis in, 594 
Murphy drip in, 594 _ 
Ochsner's treatment in, 594 
rectal salines in, 594 
starvation in, 594 
chronic, diet in, 594 
Perityphlitis, diet in, 406 
Pheasant meat, composition of, 661 
Phosphaturia, 518 
calculi in, 520 

diet for, 52 1 
causes of, 519 

daily phosphorus excretion in, 519 
decreased urinary acidity in, 519 
juvenile, 520 
nervous, 519 
phosphates in, 520 
physiological, 519 
sexual, 519 
Phosphorus content of foods, 91 
organic vs. inorganic, 90 
requirement of man, 89 
Physiological phosphaturia, 519 
Pickerel, composition of, 662 
Pies, composition of, 664 
Pigeon meat, composition of, 661 
Pike, composition of, 662 
Pineapple, composition of, 666 
Plasmon, 657 . 
Pleurisy with effusion, diet in, 325 

salt-poor, 325 
Pneumonia, Bulgarian bacilli in, use of, 
320 
diet in, 318 

Coleman's, 318 
high calory, 318 
low purine, 319 
drinks in, 320 

renal complications in, diet for, 320 
tympanites in, diet for, 320 
uric acid in blood in, 319 
Pogy, composition of, 662 
Poisoning by. canned goods, 643 
by fish, 642 

food, 641. See Food poisoning, 
by meat, 642 
by vegetables, 643 
Pompano, composition of, 662 
Pork, fresh, composition of, 661 

pickled, salted, and smoked, com- 
position of, 661 
Portal cirrhosis, diet in, Karell, 417 
milk, 417 
salt-poor, 417 
duodenal feeding in, 418 
Posthemorrhagic anemia, diet in, 537 
Postoperative diet, 601 

for appendectomy, 607 
for digestive tube, 601 



Postoperative diet for gall-bladder 
operations, 610 
for gastric operations, 601 
for gastroenterostomy, 601 
Finney's, 605 
von Leube's, 603 
for hemorrhoids, 610 
for intestinal lesions, 606 
for intubation, 611 
for rectal operations, 61 1 
for tonsillectomy, 601 
for vomiting following abdo- 
minal operations, 609 
intestinal distention, diet in, 609 
Potato in infant-feeding, 289 
Potatoes, composition of, 665 
digestibility of, 226 
sweet, 224, 225 
white, 224, 225 
Potter's modification of Karell cure in 

cardiac disease, 310 
Poultry, 192 

fresh, composition of, 661 
preserved, composition of, 661 
Pregnancy, auto-intoxication in, 629 
food requirements in, 112 
complicating nephritis in, 628 
contracted pelvis and, 629 
diet in, 626 

energy requirement during, 112 
irritable stomach in, 628 
nausea in, 626 
oversized fetus in, 629 
protein requirement in, 113 
uremia in, 628 
vomiting in, 626 
Preoperative diet, 599 

in gastric operations, 600 
in laparotomy, 599 
Preserved eggs, 198 

fish, 191 
Pretzels, composition of, 664 
Proprietary foods in infant feeding, 280 
Protein, 18 

absorption of, 38 

in rectal feeding, 619 
amino-acids in, 165 
character of, 164 
classification of, 166 
constitution of ; 76 
digestion of, in stomach, 30 
efficiency in diet, 79 
foods, 163 

bacterial changes in, 171 
character of, 164 
digestion of, 171 
effect of heat on, 169 
inadequate, 77 
in milk, 266 

putrefaction in intestinal auto- 
intoxication, 407 
requirement, 73 
average, 80 



700 



INDEX 



Protein requirement of children, 118 
determination of, 73 
effect of carbohydrate on, 79 

of fat on, 79 
factors affecting, 82 
of infant, 277 
minimum, 74 
of pregnancy, 113 
in relation to number of meals, 

7 8 . 
to toxic substances, 77 

subcutaneous feeding of, 623 

synthesis, 76 
Proteins in wheat, 203 
Prunes, composition of, 666, 667 
Pruritus, 433 

diabetes and, 434 

diet in, 434 

fissures and, 433 

hemorrhoids and, 433 

tobacco usage and, 433 
Psoriasis, complement-fixation test in, 
426 

diet in, protein, 427 
vegetarian, 428 

"nitrogen hunger" in, 427 

Shamberg's investigations on, 426 
Ptyalin, 25. See Salivary amylase. 
Puddings, composition of, 664 
Puerperium diet in, 630 

foods to avoid in, 630 
Pumpkins, composition of, 665, 666 
Purine bases in vegetables, 203 
Purpura hemorrhagica, 538 
Putrefaction, feces and, 44 

products of, 43 
indican, 43 
indol, 43 
Putrefactive bacteria, 43 
Pyelitis, alkaline waters in, 456 

diet in, 456 
milk, 456 

fluid ingestion in, 456 

urotopin in, 456 
Pyloric stenosis, feeding during, 299 

olive oil in, 658 
Pylorus, opening and closure of, 28 



Quail meat, composition of, 661 



Radio-active water, 254 
Radishes, composition of, 665 
Raisins, composition of, 667 
Raspberries, composition of, 666 
Rectal feeding, 618 

absorption of amino-acids in, 
619 
of carbohydrates in, 621 
of fat in, 621 



Rectal feedings, absorption of protein 
in, 619 
colon absorption in, 619 
determination of absorption in,. 

619 
Leube's formula in, 620 
metabolism in, 619 
nutritive solution in, 622 
precaution in, 622 
Riegel formula in, 620 
sugar solutions in, 622 
operations, postoperative diet for,. 
611 
Reigel's test dinner, 381 
Renal complications in pneumonia, diet 

for, 320 
Renovated butter, 233 
Respiration apparatus, 59 
Respiratory quotient, 60 
Rheumatism, acute articular, acid-pro- 
ducing foods in, 589 
complement-fixation in,. 

587 
diet in, 588 
etiology of, 587 
humoral theory of, 587 
infectious origin of, 587 
low purines in, 588 
milk mixtures in, 588 
streptococci and, 587 
chronic, alcohol in, 589 

autogenous vaccines in, 590 
digestive complications in, 590 
disease distinct from gout, 589 
feeding in, forced, 590 
focus of infection in, 590 
uric acid in, 589 
subacute, acid-producing foods in, 

589 
diet in, 589 
Rheumatoid arthritis, 596 

calcium metabolism in, 596 

diet in, 596 

etiology of, 596 

gouty manifestations in, 596 

high caloric feeding in, 598 

low calcium diet, 596 

protein allowance, 597 
reduction cures in, 598 
Rhubarb, composition of, 665 
Rice, 215, 217 

custard, composition of, 664 
in infant feeding, 289 
Rickets, in 

feeding during, 302 
Riegel's formula for rectal feeding, 620 
Ripened milk, 655 
Roberat, 657 

Rolled oats, composition of, 663 
Rolls, 222 

Roquefort cheese, composition of, 662 
Rye, 215, 218 

flour, composition of, 663 



INDEX 



701 



Salisbury diet in obesity, 501 

Tower-Smith's modifica- 
tion of, 501 
Saliva, constituents of, 26 

reaction of, 26 
Salivary amylase, 25, 26 

digestion in stomach, 26 
Salmon, composition of, 662 
Saltines, composition of, 664 
Salt-poor diet in nephritis, 452 

in pleurisy with effusion, 325 
in portal cirrhosis, 417 
Salts. See Inorganic salts, Sodium 
chloride, 
in infant feeding, 280 
in milk, 154 
Salzer's double test meal, 382 
Sauerkraut, composition of, 665 
Sausage, composition of, 661 
Scarlet fever, diet in, 584 
Schlager's test-day in nephritis, 440 
Schleip's method of dietary diagnosis of 

gout, 507 
Schmidt-Strassburger's gastric motor 

meal, 383 
Schmidt's test diet in chronic enteritis, 

387 
modified, 388 
Schweninger's dietary in obesity, 500 
Scurvy, 539 

diet in, 540 
fruit juices in, 540 
lack of vitamines in, 108, 539 
milk in, 540 
orange juice in, 540 
potato juice in, 540 
sulphur metabolism in, 541 
Second year, feeding during, 295 
Senile heart, diet in, 313 
Sexual phosphaturia, 519 
Shad, composition of, 662 

roe, composition of, 662 
Shredded wheat, composition of, 663 
Singers, diet for, 636 
Sippy's diet in peptic ulcer, 360 
Skin, diseases of, 425 

alimentary eruptions in, 425 
anaphylaxis in, 425 
gastric hyperacidity in, 425 
Johnson's classification of der- 
matoses, 425 
metabolism in, 425 

intermediary nitrogen, 425 
nitrogen, 426 
Smallpox, diet in suppurative stage of, 

. 585 

liberal feeding in, 585 

modified milk in, 585 
Smelt, composition of, 662 
Soda crackers, composition of, 664 
Sodium chloride requirement of man, 89 



Somatose, 657 

Soy beans, 204 

Spaghetti, composition of, 663 

Spanish mackerel, composition of, 662 

Speakers, diet for, 636 

Specific dynamic effect of food, 68 

Spices, 244 

Spinach, composition of, 665 

Sponge cake, composition of, 664 

Sprue, foods other than milk in, 632 

fruits in, 632 

Manson on diet in, 631 

milk cure in, 631 

occurrence of, 631 

pancreatic digestion in, 631 

rectal feeding in, 632 

strawberries in, 632 
Squab meat, composition of, 661 
Squash, composition of, 665, 666 

pie, composition of, 664 
Starch, 213 

in infant feeding, 279 
Starches, composition of, 665 
Starvation in acute gastritis, 346 
peritonitis, 594 

period in obesity, 503 

treatment of acute appendicitis, 

4°3 

Stenosis of esophagus, olive oil in, 658 

pyloric, olive oil in, 658 
Stomach, absorption in, 38 
bacteria in, action of, 43 
carcinoma of, 375 

Carlsbad water in, 376 
citrated milk in, 376 
diet in, 375 

gastroenterostomy in, 377 
gastrostomy in, 377 
Vichy water in, 376 
Weisbaden water in, 376 
contractions of, 34 
diseases of, diet in, 335 

secretory depressants in, 335 
excitement in, 335 
effect of alcohol on, 37 
emptying of, 27 

effect of acids on, 28 
enzymes in, 29 
fat in, digestion of, 31 
hemorrhage from, diet after, 369 
irritable with vomiting, diet in, 338 
passage of food from, consistency 
of, 54 
rate of, 53 
into, 27 
of milk through, 29 
of water through, 28 
protein in, digestion of, 30 
salivary digestion in, 26 
yeast in, growth of, 44 
Stomachics, 35 

Stools, abnormal, in artificially-fed in- 
fants, 29 



702 



INDEX 



Stools, abnormal, in breast-fed infants, 

273 

loose, 29 
Strauss's levulose test in diseases of 

liver and gall-bladder, 415 
Strawberries, composition of, 666, 667 
String beans, composition of, 665, 666 
Subcutaneous feeding, 623 

of carbohydrates, 624 
of fats, 624 
of protein, 623 
Succotash, composition of, 666 
Sucrose, 208 
Sugar, beet, 208 

cane, 208 

cookies, composition of, 664 

in diet, value of, 212 

digestion and utilization of, 211 

fruit or fructose, 210 

glucose, 209 

in infant feeding, 278 

invert, 210 

malt, 210 

maple, 210 

milk, or lactose, 209 

substitutes, 245 
Sugars, 208 

composition of, 665 
Sulphate water, 253 
Sulphurous water, 253 
Suralimentation in insanity, 550 
Surgical operations, diet in relation to, 

599 

Swiss cheese, composition of, 662 



Tachycardia, diet in, 305 
Tapioca, composition of, 665 

pudding, composition of, 664 
Tea, 246 

effect of, 250 

of kind of water on decoction, 

2 47 
infusions of composition of, 247 
Test meals, gastric, 381. See Gastric 

test meals. 
Tetanus, diet in, 590 
feeding in, 590 
Murphy drip in, 590 
Thyroiditis, acute, diet in, 613 
Tibbie's milk cure in obesity, 500 
Tobacco, cardiac disease and, 316 
Tomato soup, composition of, 668 
Tomatoes, composition of, 665, 666 
Tower-Smith's modification of Salis- 
bury diet in obesity, 501 
Tropon, 657 

Trout, composition of, 662 
Tuberculosis, 326 

complications of, diet in, 333 
diets in, 329 

for children of tuberculous in- 
heritance, 330 



Tuberculosis, diets in, Bardswell and 
Chapman's, 333 
King's, 332, 333 
of Loomis Sanitarium, 333 
eggs in, 331 
fats in, 331 

feeding in, rules for, 334 
milk in, 331 
plan of feeding in, 330 
protein ration in, 327, 328 
special foods for, 331 
Turkey meat, composition of, 661 
Turnips, composition of, 665 » 
Tympanites in pneumonia, diet for, 320- 
Typhlitis, chronic, diet in, 406 
Typhoid fever, 568 

acidosis in, 570 
basal metabolism in, 63 
Coleman's milk mixtures in, 573 
Coleman and Shaffer on energy- 
requirements, 571 
diet in, 567 

carbohydrates in, 570 

in complications, 583 

in diarrhea, 583 

fats in, 573 

fluids in, 574 

in hemorrhage, 583 

high calory, 575 

milk in, 573 

in nausea and vomiting,. 

583 
No. 3, 580 

No. 4, 581 
No. 5, 581 
in perforation, 584 
soft, 581 

in tympanites, 583 
without milk, 582 
effect of carbohydrates on in- 
testinal flora, 570 
of proteins on intestinal 
flora, 570 
energy requirement in, 572 
feeding in, general directions 
for, 573 
inadequate diet, 568 
liberal diet, 569 

bacteriological 
basis of, 569 
needs of, 571 
physiological 

basis of, 569 
results of, 572 
older diet, 568 
fermentation stools in, 583 
food absorption in, 571 
Kendall's bacteriological ex- 
periments in, 570 
Kinnicutt's liberal diet in, 573 
lactic acid bacilli for, 571 
morphine in hemorrhage for,583 



INDEX 



703 



Typhoid fever, nitrogen metabolism 
reduced bv carbohydrates, 

570 

protein requirement in, 571 
proteins in, 573 
typhoid state in, 568 
water intake in, 584 



U 



Ulcer, peptic, 349. See Peptic ulcer. 
Ulceration of intestines, diet in, 392 
Unconscious patients, feeding of, 640 
Urea, excretion of, 50 
Uric acid in blood in pneumonia, 319 
excretion of, 51 

effect of diet on, 51 
Urine, composition of normal, 50 



Veal, composition of, 660 
Vegetable foods, composition of, 663 
for aged, 526 
oils, 235 
poisoning, 643 
soup, composition of, 668 
Vegetables, 238-244 

composition of, 239, 241 
cooking of, 242 

losses in, 243 
green, iron in, 241 
in infant feeding, 288 
place of, in diet, 238 
purine bases in, 204 
Vegetarian diet, 645, 648 
Vegetarians, metabolism of, 647 
Vermicelli, composition of, 663 
Vinegar, 245 
Vitamine content of butter, 105 

requirement of children, 120 
Vitamines, 20, 102 
antiscorbutic, 103 

occurrence of, no 
fat-soluble A, 20, 103 
water-soluble B, 20, 103 
Vomiting in artificially-fed infants, 290 
in breast-fed infants, 272 
cyclic, feeding during, 300 
following abdominal operations, 

diet in, 607 
from acute gastric dilatation, diet 
in, 608 
Von Leube's diet after gastroentero- 
stomy, 603 
in peptic ulcer, 350, 351 

Lockwood's modification 
of, 351 
gastric motor meal, 382 
Von Xoorden's diet in obesity, 496 

method of dietary diagnosis of 
gout, 507 



Von Noorden on sugar production in 
diabete smellitus, 468 



W 



Walnuts, California, composition of,. 

667 
Water, 20 

crackers, composition of, 664 
in infant feeding, 280 
iron, 254 
lithia, 253 
mineral, 252 

minimum effective dose of, 256 
value of, 254 
passage of, through stomach, 28, 

101 
radio-active, 254 
requirement of children, 121 

of man, 99 
sulphate, 253 
sulphurous, 253 
Water-soluble B, 20, 103. See Vitamines 
Watermelons, composition of, 666 
Weaning, 274 

Wegele's diet in gastric atony, 373 
Weisbaden water in carcinoma of stom- 
ach, 376 
Wheat, 215, 218 

in diet, place of, 218 
flour, composition of, 663 
milling of, 220 
proteins in, 203 
value of, in cooking, 219 
Wine whey, 654 
Wines, 260 
Witte's peptones, 657 
Woman's milk, 263 

characteristics of, 264 
composition of, 265 
effect of diet on, 268 
quantity of, 264 



Xerophthalmia, diet in, 54; 



Yeast, growth of, in stomach, 44 
Yellow fever, enteroclysis in, 591 

feeding in first stage of, 591 
by rectum in, 591 
in severe vomiting of, 591 
three stages in, 591 



Zwieback, composition of, 664 



r 



LIBRARY OF CONGRESS 

0002L,037037 



■■ 






